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Client Intake Form

Please answer the following questions as completely as possible to help your counselor offer suggestions tailored to your lifestyle and needs. All information submitted on this form will be kept confidential. Please fill out within 24 hours of your appointment time.

Client Information

Birthday
Month
Day
Year
Have you recently experienced weight change?
Are you currently pregnant?
Are there clots in your menstrual blood
How would you describe your flow?
Light
Medium
Heavy
Is it ok for your Ayurvedic Health Counselor to discuss your self-care suggestions and the information submitted with her co-counselor?
Yes
No

Disclaimer

I acknowledge and understand that the services provided by East + West Wellness and its counselors are not offered as a substitute for medical care, diagnosis, or treatment by a licensed healthcare professional. I understand that no claims have been made by East + West Wellness or its practitioners to diagnose, treat, cure, or prevent any disease or medical condition. I further understand that I should consult with my physician or qualified healthcare provider for any questions regarding my health, medical conditions, medications, or treatment plans. By signing below, I voluntarily assume full responsibility for my own health and wellness choices and release East + West Wellness and its counselors from any liability in connection with the services provided.

Acknowledgment and Consent


I have read and fully understand the above disclaimer. I acknowledge that the services provided by East + West Wellness and its counselors are not a substitute for medical care and that no claims to diagnose, treat, cure, or prevent any medical condition have been made. I agree to take full responsibility for my health and wellness decisions.

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