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 No Phone * (###) ### #### Email Address * Personal Wellness Information Birthday * For special Bonus in your birth month MM DD 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 * Yes No Address for at home sessions Address 1 Address 2 City State/Province Zip/Postal Code Country Thank you! We look forward to meeting you. Click Here for our Privacy Policy
