Wellness Consult Intake, Barbara Christensen, HLWC, CPT, CA, NTP
Women's Wellness Consult Intake Form / Be Light Create LLC

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.
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Name : First and Last *
Age *
Email *
Country of birth (This helps with Metabolic Typing & Dietary Issues) *
Food sensitivities / allergies *
Post from childhood and current, when they changed.
Current Weight *
Has your weight fluctuated in the last 6 months? A year? Please explain: *
Phone Number *
List if cellular, home or work
Best time to contact
If your appointment is not already set....
Best day to contact
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What time zone are you in? *
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 *
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 _________ *
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? *
What issues are you looking to solve today? *
What is preventing you from reaching your goals/optimal health? *
How important is it to you to feel good? Be well? Feel happy? *
What are you willing to change? *
I take the following vitamins/supplements daily: *
What supplements do you take ONLY occasionally, and why?
What health issues do you want to avoid or need targeted support for? *
Have you ever had any genetic testing done? And if so do you know what your mutations are? *
examples for MTHFR, MTRR, COMD, VDR
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)
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)
What is is about previous diets that just hasn't worked for you? *
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 Shamanic practices and diagnostic tools, Aromatherapy, Reiki Usui Shiki Ryoho and Karuna Ki, Access Bars, Ataana Method; and/or Holistic Coaching Techniques including Hypnotherapy, REBT, Meditation and Mudras. *
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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. *
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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. *
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Wellness Session Details
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:

Wellness Consulting I have a monthly packaged deal that is 45-minutes per week for $189/mo (which covers 4 weeks per month, for those months where there is a “fifth” week).

Individual Wellness Sessions book out at $65/per 45-minutes.

For retail nutritional support customers I do a special of two 30-minute Wellness Consulting sessions per month for $65.

Awareness Sessions are $111 for 45 minutes where we work on whatever you want in terms of life (nutrition, wellness, relationships, career, passions, purpose) and can be as simple as talking through things with intuitive support or as integrative as working one-on-one on your vision using art as a mediator.

If you need suggested meal ideas I have a $20/month e-book program with recipes, suggested meal plans, and a little education to mix in. February the focus is on removing added sugar in the diet. I offer it as a gluten-free and dairy-free plan with modifications to add in animal products as desired.


Outcalls available with travel fee. Fees are subject to change. {Outcalls are not available currently}        


     
What are you looking to book? *
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