Section 2

It is my choice to receive treatment. I understand that the information given below is strictly confidential and will be for no other purpose than to assist the facilitator in providing a suitable session which would take into consideration my specific requirements.

Name

First Name

Last Name

Are you on Facebook?

Yes

Phone

(###)

###

####

Email Address

Personal Wellness Information

Birthday

For special Bonus in your birth month

YYYY

List the Food you eat regularly

Please list any forms of medication or herbal supplements you are taking

Any other Care or Concerns

Commitment and Consent for Care

Lifestyle Architecture is intended to educate me about the dynamics of health that are within my control, including patterns of movement and holding, responses to stress, and accumulation of tension. It is a holistic approach to bridging mind and body. Together we will assess physical signals of diminishing health and develop a treatment plan to respond to them in ways that promise vitality, balance, and spirit. Selecting "Yes" below indicates my willingness to proceed. Information provided to me by the facilitator is for educational purposes and is not a claim for cure or mitigation of disease, but rather an adjunctive approach, supplying individual needs that otherwise might be lacking in today’s lifestyle. I understand that my well being is in direct relation to how well I treat my being.

Select

Address for at home sessions

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Initial Intake