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* 1. Your contact information

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* 2. Are you interested in participating in:

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* 3. Informed Consent
A. A Wellness consultation with Brooke is not a medical evaluation. We work with Ayurvedic and Access Consciousness tools to implement lifestyle changes, shifts in your dietary patterns and possibly herbal supplementation as well as yoga, aroma, color, sound and massage therapy. I'm excited to assist you in stepping beyond any current physical and mental limitations in your life, and I want to invite you to live this life in a space of choice and infinite possibilities. What else is possible that we haven't even considered? 

B. Brooke Pilkington is a Certified Ayurvedic Practitioner, an Access Bars Facilitator and a Doula not a medical Doctor.

C. If during a consultation findings suggest a possible medical imbalance, your practitioner will refer you to a medical professional.

D. Ayurveda is the traditional healing system of India, which is based on the idea that each person is unique. Using Ayurvedic and Access Consciousness tools we will design a program that is based on the understanding of your unique body and the unique nature of any imbalances in your life. Our goal is to create health, ease and joy within your body and mind. How does it get any better than that?


Financial Agreement
A. There is a charge of $60 for a 30 minute session with Brooke.
B. There is a charge of $60 for a Children's Energetic Body Session with Brooke.
C. There is a charge of $100 for a 60 session with Brooke.
D. There is a charge of $150 for a 90 minute session with Brooke.
E. The payment for all Gathering of the Goddesses events are due 1 week before the date of the gathering.
H. Any herbs, oils, body work or other products are sold separately from the consultation price.
H. Brooke is open to trade, but arrangements must be made prior to the visit.
I.  Beeing Well does not bill insurance companies for services or herbal products.

Please specify below which financial agreement you are choosing and add your electronic signature.



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* 4. Past Medical History or Family Medical History

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* 5. Food and Supplements

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* 6. Daily Rhythms

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* 7. Digestion

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* 8. Elimination: please mark any that apply

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* 9. Psychology: Please mark any that apply

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* 10. Is there any other information that would be helpful for me to know about your health?

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