Wellness Consult Intake, Barbara Christensen, HLWC, CPT, CA, NTP
Women's Wellness Consult Intake Form

DISCLAIMER: Barbara Christensen, your holistic coach, is not a medical doctor. Barbara Christensen is not engaged in rendering professional medical advice or services to the individual reader. The ideas, procedures, and suggestions contained within your coaching session and any additional programs or emails are not intended as a substitute for consulting with your physician. All matters regarding your health require medical supervision. Barbara Christensen is not be liable or responsible for any loss or damage allegedly arising from any information or suggestions within any of her coaching or related programs and marketing. You, as someone that has reached out to me as a certified aromatherapist, certified personal trainer and holistic life coach, nutritional therapy practitioner with a diploma in personal nutrition and are totally and completely responsible for your own health and healthcare.

Please check off that you agree to the above information
Name : First and Last *
Your answer
Age *
Your answer
Email *
Your answer
Country of birth (This helps with Metabolic Typing & Dietary Issues) *
Your answer
Food sensitivities / allergies *
Post from childhood and current, when they changed.
Your answer
Current Weight *
Your answer
Has your weight fluctuated in the last 6 months? A year? Please explain: *
Your answer
Phone Number *
List if cellular, home or work
Your answer
Best time to contact
If your appointment is not already set....
Best day to contact
What time zone are you in? *
Your answer
Rate your health: *
Rate yourself (1 - Poor, 10 - Excellent)
I drink Enough Water *
Rate yourself (1 - Poor, 10 - Excellent)
I drink ____ Oz of water a day *
Your answer
I eat healthy (Clean, Whole Foods) *
Rate yourself (1 - Poor, 10 - Excellent)
I am at my ideal weight *
Rate yourself (1 - Poor, 10 - Excellent)
My goal is _________ *
Your answer
Rate your current health *
Rate Yourself (1 - Poor/Life Threatening, 10 - Healthy/ No Issues or Risks)
How is your fitness health *
Rate Yourself (1 - I don't exercise, 10 - I exercise 6x a week hard)
I avoid harmful foods/substances *
I get adequate rest *
Yes - over 7 hours a night, No - Under 7 hours a night
I feel happy and calm most of the time *
I feel calm in the evening *
I live pain-free *
I am full of energy and vitality *
I manage stress well *
I support my body's health needs *
What life's little emergencies have been your struggles over the last six months? *
Your answer
What issues are you looking to solve today? *
Your answer
What is preventing you from reaching your goals/optimal health? *
Your answer
How important is it to you to feel good? Be well? Feel happy? *
Your answer
What are you willing to change? *
Your answer
I take the following vitamins/supplements daily: *
Your answer
What supplements do you take ONLY occasionally, and why?
Your answer
What health issues do you want to avoid or need targeted support for? *
Your answer
Have you ever had any genetic testing done? And if so do you know what your mutations are? *
examples for MTHFR, MTRR, COMD, VDR
Your answer
Do you have/had any of the following? *
My current biggest issue is? *
Food item sensitivities: Long Term *
What items have you not been able to eat, even though you are not allergic to them (over a year)
Your answer
Food item sensitivities: Short Term *
What items have you not been able to eat, even though you are not allergic to them (within the last three months)
Your answer
What is is about previous diets that just hasn't worked for you? *
Your answer
Interested in working with *
I understand that Barbara Christensen does not diagnose or treat physical, emotional or mental illness. I understand that Barbara Christensen assesses and addresses the subtle body energies that pattern the physical, emotional and mental well-being. I acknowledge and confirm that my treatment was explained prior to the service being performed. I understand and consent to holistic coaching and/or body energy system assessment and subtle energy balancing which may include a wide variety of Aromatherapy, Reiki Usui Shiki Ryoho and Karuna Ki, Access Bars, Ataana Method; and/or Holistic Coaching Techniques including Hypnotherapy, REBT, Meditation and Mudras. *
Initial Below
Your answer
I understand and acknowledge the medically acceptable alternatives and risks associated with the proposed treatment. I understand that most people report significant progress towards their goals from working with an Energy Practitioner and/or a Life Coach, however there are no guarantees of outcomes. Each party agrees to hold harmless the other party and its agents, officers, and employees from and against any and all liability, expense, including defense costs and legal fees incurred in connection with claims for damages of any nature whatsoever including but not limited to, bodily injury, death, personal injury, financial or business losses, or property damage arising from this voluntary relationship. *
Initial Below
Your answer
What to Expect: You are entirely unique, so the pace of your progress towards your goals will also be unique. Since the experience of wellness in body, mind and spirit has direct correlations in the subtle energy fields, addressing subtle energies has activates healing. Essentially, your wellness is an inside job, and I make no claims about what your individual outcomes will be along the way. I act as an ally on your healing journey and help you discover the next steps in your process. You are in complete control of the pace of your progress. I may teach you holistic techniques that you can use every day to enhance and extend the benefits depending on our session work. *
Initial Below
Your answer
Free Consult
This form will provide you with a phone or video one-on-one, 30-minute holistic and/or energy consultation.

Should you desire to continue please be aware of the following:

Session Cost: $100 per hour unless other arrangements or bundles are created. Recommended session time is 1.5 hours = $135, or two hours = $170 Cash, Check, and credit cards are accepted.
Outcalls available with travel fee. Fees are subject to change.


Financials and Late Policies:
1. Payment for services is due at the time services are rendered unless other arrangements have made.
2. Please give 48 hours notice to cancel appointments when necessary, to avoid being charged for the appointment.
3. Please be on time. If you are late, your session may be shorter in order for me to honor other clients. You will still be responsible for the full time you have scheduled.
4. Returned check fees are the financial responsibility of the client.
5. Health insurance companies cover Reiki only when it’s woven into comprehensive treatment programs such as physical therapy, massage or palliative care or as part of routine care during a hospital stay. To continue to do the best job possible for you, using the latest in alternative practices, we cannot accept or file health care insurance claim forms.
6. We are not participating providers in Medicare, Medicaid or any other government sponsored programs or insurance plans.
7. You are responsible for all services provided at the time of treatment and take full responsibility for all bills incurred for treatment.

Barbara Christensen, CA, NTP, CRM, CBP, HLWC, CPT
www.PaleoVegeo.com / www.BijaCoaching.com

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