BWWB Confidential Client Intake Form
Welcome to this amazing journey where everything can change and anything is possible! For ease with payment you are welcome to use; Paypal: PayPal.Me/BrookePilkington or Venmo: @BrookePilkington
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Email *
What is your first and last name? *
What is your birth date?
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What is your phone number? *
Where are you from? Where are you currently living?
Are you interested in participating in:
Informed Consent  

1. Wellness consultations with Brooke are not medical evaluations. We work with Ayurvedic and Access Consciousness tools to implement lifestyle changes, shifts in your dietary patterns and possibly herbal supplementation as well as yoga, aroma, color, sound and massage therapy. 

2. Brooke Pilkington is a Certified Ayurvedic Practitioner, an Access Certified Facilitator and a Doula not a medical Doctor.  

3. If during our consultation findings suggest a possible medical imbalance, your practitioner will refer you to a medical professional.                              

4. Ayurveda is the traditional healing system of India, which is based on the idea that each person is unique. Using Ayurvedic and Access Consciousness tools we will design a program that is based on the understanding of your unique body and the unique nature of any imbalances in your life. Our goal is to create health, ease and joy within your body and mind. How does it get any better than that?
Financial Agreement
A. There is a charge of $75 for a 30 minute session with Brooke.
B. There is a charge of $150 for a 60 session with Brooke.
C. There is a charge of $225 for a 90 min session with Brooke.
D. There is a charge of $300 for a 120 minute session with Brooke.
E. There is a charge of $150 for seasonal cleanses with Brooke. 
F. The payment for all retreats are due 1 month before the date of the event.
G. Any herbs, oils, body work or other products are sold separately from the consultation price.
H. Brooke is open to trade, but arrangements must be made prior to the visit.
I.  Beeing Well does not bill insurance companies for services or herbal products.

For ease with payment you are welcome to use; 
Paypal: PayPal.Me/BrookePilkington or 
Venmo: @BrookePilkington

Please specify below which financial agreement you are choosing and add your electronic signature.
 *
Past Medical History
Foods & Supplements
Please give me some dietary details about the above question if needed and list any medications or supplements you are taking and dosages.
What are your sleep and wake times?
How often and what time do you eat your meal?
Describe your exercise patterns:
Digestion: please mark any that apply
Elimination: please mark any that apply
 Psychology: please check any that apply
Do you have any current limitation with your body, your business, your money flows or your relationships that you are ready to out create???  
Are you ready to let go of your limiting points of view that are keeping you stuck???
Clear selection
Do you have any questions or concerns for me??? 🌻
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