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CONSULTANT APPLICATION
Life Coach Consultation Application
PERSONAL INFORMATION
Guardian Name *
Name of Child *
Child's Birthdate *
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Phone number *
Email *
Address
Our family or my child currently receives:
YOUR CHILD'S INFORMATION
Goal of Nutritional Consultation: *
Hospitals where your child is treated: *
QUESTIONS
Describe your child's diagnosis and disability. Please include the date that your child was diagnosed. *
Briefly explain what treatments or diets have been tried in the past.  *
What is your child's current diet like today? *
CONSENT
Name *
Date of Birth *
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MEDICAL DISCLAIMER: I understand that the medical information relayed pursuant to this authorization could contain information concerning drug related conditions, alcoholism, psychological conditions, psychiatric conditions, and/or blood borne infectious disease, which are subject to federal and/or state restrictions on disclosure. I understand that if the person or entity that receives the information is not a health  care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these regulations. I hereby affirm that I have read and fully understand the above statements and consent to the disclosure of the medial information for the purpose and extent stated above. 
By clicking "yes" you agree to abide by the Terms of Service outlined above. *
Electronic Signature *
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