Intake Form

Intake Form for Coaching

All information provided in this form is confidential.
Date

MonthDayYear
Date
Would you like to schedule a:

Living & Aging Well Coaching $150.00. 90 minutes includes Breath Medicine Zoom Prepaid PayPalAstrology for Living & Aging Well/Gene Keys Natal Chart Coaching $150.00/Zoom Prepaid PayPalEar/Foot Reflexology/Reiki 75 Minutes. Office $95.00 Ear Seeds/ Essential Oils $25.00 (office) check/cashBreathe & Sound coaching $75.00-$90.00 sliding scale 45 minutes Zoom Prepaid PayPal
Your name:
Address:

Street Address

CityState / Province

Postal / Zip Code
Date of birth

MonthDayYear
If you would like Astrology Coaching please add:
Your Full Name at Birth

First NameMiddle NameLast Name
Your Place of Birth

Street Address

Street Address Line 2

CityState

Zip Code
Your Birth Time
E-mail:
example@example.com
Phone Number:

Area CodePhone Number
Reason for consultation and intention:
Any known allergies:
Please list any prescription medications, herbs or supplements:
Tell me about you? Are you happy? Maritial status? Traumas? How can I best assist you?
Diet/Nutrition currently:
Past medical history:
Injuries/pain (please include where & for how long):
Vaccinations:
Any additional information to contribute (such as stress level from 1-10), and what are your goals? Are you getting restorative sleep?
INFORMED CONSENT FOR COACHING

Karen Eddings, RN, MHN
Name*

First NameLast Name
I, the undersigned, agree to secure the services of Karen Eddings, RN, MHN, for wellness and lifestyle medicine coaching.

I understand Karen is a Registered Nurse with a Master's in Nutrition and has extensive education and experience in wellness and lifestyle medicine. Karen will not diagnose any disease or condition but will use for discussion the diagnosis from my doctor if I have one.

I understand that Karen will recommend a range of healing modalities designed to improve my well-being. Some of the modalities she may suggest are lifestyle medicine awareness, whole foods nutrition, Emotional Freedom Therapy, aka EFT, and Essential Oils.

I understand that Karen makes no claims for any cure, and will recommend lifestyle changes that she knows will make a difference in my wellbeing and energy. I will be educated about these therapies and how they can support me.

I fully understand that I am responsible for my physical, mental, emotional, and energetic wellbeing.

Karen Eddings, RN, MHN is released from liability as a result of this consultation and therapies.

I understand this is NOT a substitute for medical care.

I have read and understand the terms of this consent form and am willing to go ahead to discover and experience the benefits of these interventions.

Karen has a “Do no harm” philosophy.
Signed:*

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Date:*

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Date
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Intake Form for Coaching

INFORMED CONSENT FOR COACHING