Wellness Session Intake Form

Wellness Session Intake Form

Welcome! I'm so glad you're here. This session is designed to give you simple, personalized steps you can start right away.
PLEASE NOTE:

This session is educational only and does not replace medical care. I do not diagnose, prescribe, or provide emergency services. If you have urgent health concerns, call 911 or your healthcare provider.
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Email Address
example@example.com
What state do you reside in?
What's the main thing you'd like to focus on during your session?

Better SleepMovement & MobilityStress ReliefHydration & Body BasicsNutrition & EnergyMidlife ChangesUnderstanding medications or Doctor's adviceOther
Are you taking any medications? If yes, please add each medication below. If you are unsure, leave it blank.
Is there anything else you'd like me to know before our session?
Additional information will help me plan your next steps.
Wellness Session Consent
I understand that this session is for educational purposes only and does not replace medical care. I agree to seek appropriate medical attention for any urgent and serious concerns.

I understand that our session conversation and my data will be strictly confidential.

I release Megan Stockman, RN, BSN and hold harmless against any claims, expenses, damages, and liabilities.
Client Signature

Clear
Date Signed

MonthDayYear
Date
Should be Empty:

Wellness Session Consent