Thrive Worldwide Wellness Initial Intake Form

Thrive Worldwide Wellness

Client Initial Intake Form
Thank you so much for reaching out to Thrive Worldwide Wellness and for taking the first step towards greater health!

This intake form is required before any appointment requests can be granted. Once you complete and submit this form you will receive an email from one of our team members to help book your 30-minute wellness consultation with me, Amber Summers, HHP, HNC, Founder of Thrive Worldwide Wellness.

The information you provide in this Intake form helps me to better understand your case and make the most of the short time we will have together. This form is protected under HIIPA standards for client privacy so please feel safe to share any medical conditions or concerns.

I'm looking forward to meeting you and hearing about your wellness challenges and goals. It is my greatest passion to support individuals in healing themselves and living their best life!

If you have any questions or concerns leading up to your scheduled visit, please contact us directly through email at thriveworldwidewellness@gmail.com.

Again, thank you for your inquiry and I look forward to meeting with you soon!

Yours in Wellness,

Amber
Basic Information
Name*
Email Address*
example@example.com
Time Zone*
Phone: Home #
Phone: Cell #
Address*

Address

Street Address Line 2

CityState

Zip Code
Birthdate*

MonthDayYear
Date
Sex Assigned at Birth

MaleFemale
Current Gender

MaleFemaleOther
Referred By (if applicable)*
If not referred by a person or organization, please enter “N/A”.
Emergency Contact Information
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone
Occupation
How would you like to be notified of appointments?

TextEmailBoth
Marital Status
Number of Children
Primary Care Physician
Primary Complaint(s): Please list major symptoms and concerns*
Secondary Complaint(s):
Are you currently experiencing pain as a result of these symptoms?

YesNo
If yes, please describe the pain:
When did the pain begin?
Medical History: Please list any and all medical conditions, dates of occurrence and treatments. Include surgeries, accidents, and other traumas, etc. *
Enter “N/A” if not applicable.
List of Allergies/Sensitivities*
Enter “N/A” if not applicable.
Have you taken antibiotics in the past six months?*

YesNo

Medications: Please list all medications and their intended use

	Medications	Intended Use	Dose
1
2
3
4
5
6
7

Supplements: Please list all supplements and their intended use

	Supplements	Intended Use	Dose
1
2
3
4
5
6
7

Family History: Please list any and all diseases/conditions that run in your family
Symptoms: Please check all that apply to you personally in the last 6 months

Abdominal PainAddictionAlcohol UseAnxiousnessArthritisBlood ClotsBreathing DifficultyBroken Bones/FracturesCancerChest PainChills/FeverCirculatory ProblemsCold Hands/FeetColitisConstipationCoughCrampingCystic TumorsDental fillings/ Metal fillingsDepressionDiarrheaDiabetesDifficulty ConcentratingDizzinessEpilepsy/SeizuresExcessive PMSFaintingFatigueFrequent ColdsGenital TroubleHeadachesHealth ComplicationsHeartburnHeart DiseaseHeart PalpitationsHigh Blood PressureHyperthyroidismHypothyroidismHysterectomyInsulin PumpIrritabilityJoint ReplacementKidney DiseaseKidney StonesLimited Use of Limbs/ParalysisLiver DiseaseLow Blood SugarLower Back PainLung DiseaseMetal ImplantsMigraine HeadachesMuscle StiffnessNauseaNeck PainNeurological ProblemsNon Rx Drug UseNumbnessOsteoporosis/OsteopeniaPacemaker/DefibrillatorPoor AppetitePoor CoordinationPregnancyProblems EatingRectal PainRelationship ChangesRoot CanalSciatic PainSinus TroubleSkin EruptionsSore ThroatSpinal ProblemsStrokeSwollen AnklesTension in Neck and ShouldersThoughts of SuicideToo Much SleepToo Little SleepUlcersWeakness in BodyWeight GainWeight LossOther
Have you ever consulted with any of the following:

AcupuncturistChiropractorDoctor of NaturopathyIridologistLife/Wellness CoachMassage TherapistMedical DoctorNutritionistPhysical TherapistPsychiatristReflexologistRolfer
Any Other Specialists
How did you hear about us? Check all that apply:

EventFriend/FamilyFacebookHouse of NutritionInstagramInternet SearchNatural AwakeningsPractitioner of ThriveRadioWebsiteWEI LabsYelpOther
What topics are you most interested in learning more about?

Acupressure/Acupuncture TCMAromatherapy/Essential OilsDetoxificationHolistic MedicineHolistic Certification ClassesHomeopathyHypnosisIridologyLife CoachingLyme SupportMagnetic Therapy (PEMF)MassageMeditationMetabolic RebootNutritionOrganic Skincare/FacialsPast Life RegressionRaw Foods/JuicingReflexologyReikiSound TherapySupplementsTai Chi/Qi GongWeight LossYoga
I verify that, to my knowledge, all of the information listed above is accurate.
Signature*

Clear
Date*

MonthDayYear
Date
Property of Thrive Worldwide Wellness
Scheduling and Cancellation Policies & Procedures

Holistic Healthcare & Nutrition Consultation Disclaimer
Thrive Worldwide Wellness (Thrive Wellness Center LLC) provides virtual holistic healthcare and nutritional consultations designed to support the body’s innate ability to restore balance and resilience.

Certified Holistic Healthcare Practitioners are not licensed medical doctors.
The techniques, evaluations, and recommendations provided are not medical diagnoses.

For diagnosis, treatment of disease, or medical emergencies, please consult your licensed physician or seek emergency medical care.

Services Offered
Holistic consultations utilize Asian and European traditional evaluation techniques. These techniques may include: health history interview, evaluation of the tongue, face and skin, fingernails, and irises (Iridology).

Recommendations may include dietary changes, lifestyle guidance, cleansing strategies, and the use of vitamins, supplements, and/or homeopathic remedies to support overall wellness.

Virtual Practice Model
Thrive Worldwide Wellness is a 100% virtual practice.
All appointments are conducted online via Zoom or Moxo, our client communication portal.

Prior to Your Appointment
Clients are responsible for:

Having a stable internet connection

Downloading and testing the Zoom app on their computer or mobile device

Joining the appointment on time

Missed appointments due to technical difficulties on the client’s end are treated as a no-show.

Scheduling & Appointment Management
Because our practice operates at full capacity:

Appointments must be scheduled in advance to reserve your place on the calendar
Clients are encouraged to schedule appointments 2-4 weeks in advance to secure your place on the schedule

Holding a future appointment time is the only way to secure that space.

Appointment Confirmations
Clients will receive appointment reminders and/or confirmation requests.

Timely confirmation is required for your initial visit
We request a minimum confirmation within 48 hours of visit
Failure to confirm may result in the appointment being released to another client

Cancellation & Rescheduling Policy
We value both your time and our practitioners’ time.

A minimum of 24 hours notice is required to cancel or reschedule an appointment. A 50% cancellation fee will be charged to the card on file for late cancellations.

Cancellations made with proper notice will not incur a fee

No-Show Policy
A No-Call / No-Show significantly impacts our ability to serve other clients.

No-Shows will be charged the full value of the appointment to the card on file

We understand emergencies happen and may offer a one-time courtesy waiver for truly extenuating circumstances, at our discretion.

Repeated no-shows may result in loss of scheduling privileges.

Client Responsibility & Acknowledgment
By scheduling services with Thrive Worldwide Wellness, I acknowledge and agree that:

I have disclosed all known medical conditions and provided accurate health information

I will keep my practitioner informed of any changes to my health status

I understand that Thrive Worldwide Wellness and its practitioners are not liable for omissions or undisclosed information

I have reviewed and agree to all scheduling, cancellation, and no-show policies

Acknowledgment of Policies
I have read, understand, and agree to abide by the Thrive Worldwide Wellness (Thrive Wellness Center LLC) Scheduling and Cancellation Policies & Procedures.
Client / Guardian
Signature*

Clear
Date*

MonthDayYear
Date
Client Privacy Acknowledgement

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my health information. I understand that this information can and will be used to:
- Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved directly and indirectly in that treatment.
- Obtain payment from third-party payers (if applicable).
- Conduct normal healthcare operations such as quality assessments and practitioner certifications (if applicable).
I have been informed by Thrive Wellness Center, LLC of the Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you may restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand Thrive Wellness Center, LLC is not required to agree to my requested restrictions, but if Thrive Wellness Center, LLC does agree then Thrive Wellness Center, LLC is bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that Thrive Wellness Center, LLC has taken action relying on this content.
Client / Guardian
Signature*

Clear
Date*

MonthDayYear
Date
Thank you for completing our intake form. A member of our team will contact you by email soon to help schedule your consultation. Feel free to email us at thriveworldwidewellness@gmail.com if you do not hear from us within 3 business days.
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