Discovery: Aromatherapy Consultation
Holistic Aromatherapy Consultation: for physical, emotional, mental, and spiritual well-being. All consultations are personalized to meet your individual wellness goals and lifestyle. Easy to implement and create shifts in your health.
Zyto compass consultations: bio-communication technology that assesses your body's unique bio-markers to optimize essential oils and supplements recommendations. No more guessing games. Simply allow the Zyto compass to read your skin's galvanic response! FDA approved device.
*DISCLAIMER: I take client confidentiality very seriously. Your responses on this form are safe and protected. I honor and value your openness and vulnerability in revealing such intimate details of your life.
Consultation fee: $100+ depending on a service and need.
Step 1: Complete Discovery Questions below.
Step 2: One on one phone conversation with me ( 5 min.) to schedule session.
Name (first, last)
When is the best time to reach you?
What are your current health goals? What would you like to change or improve for your health and wellness?
Do you have sensitive skin? If so, please list any issues you experience. Do you have any allergies or sensitivities to oils, lotions, scents, foods, medicine, plants?
Rate your level of stress with (10 = overwhelming and 1 = mild).
Do you frequently suffer from stress? Please EXPLAIN (ex., triggers, lifestyle, going through changes, work stress, grief)
Do you exercise or engage in physical activity? What kind?
Do you have any specific spiritual/religious practice? Describe.
Are you pregnant or breastfeeding?
Are you currently taking any medications or supplements? If so, please list.
Have you had an aromatherapy consultation in the past? If so, what was your experience? Any successes?
What type of consultation are you interested in?
Holistic Aromatherapy Consultation (Skype or phone)
Zyto Comapss Screening (in person)
Holistic Aromatherapy Consultation & Zyto Compass Screening (in person)
What do you find the most challenging in achieving your health/wellness goals?
Please share any additional information about your physical and/or emotional health history that you feel I need to be aware of.
Do you have any questions/concerns that you want me to address during phone call? Please list.
Informed Consent: Aromatherapy is incredibly healing art and science that supports and enhances the individuals’ ability to heal and maintain health. I understand that this consultation is designed to gather information so that my practitioner is able to design and create aromatic products based upon my unique needs and goals.I understand that my aromatherapy practitioner, Irina Gubenko, does not diagnose, prevent or treat any illness, disease, or any other physical or mental condition. I understand that this is not a substitute for medical treatments and it is recommended that I see a qualified professional for any physical or mental condition that I may have. I have read the above information and I hereby give my permission for Irina Gubenko to design an aromatic program for me based upon my unique needs and goals.I understand that essential oils and aromatherapy is a complementary holistic therapy and not intended to treat, diagnose, and/or cure any medical issues. I affirm that I have answered all questions accurately and honestly and realize the importance of notifying the practitioner of any changes that may affect my health profile and understand that there shall be no liability on the practitioner’s part should I forget to do so. I know that I need to seek medical attention by a proper qualified health professional when appropriate. I understand that all my information is strictly confidential and maintained at all times. I appreciate the practitioner’s dedication to using the highest quality, therapeutic grade essential oils. Please print your name in the box below to consent.
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