Angelia Claudette Health + Wellness Client Profile Form

Client Profile Form

Angelia Claudette Health + Wellness Coach
Hello Beautiful Souls! As my client I want to ensure that you are properly prepared for your sessions and that your client profile remains current in our system.

This form allows for things to remain sychronized to provide the highest level of care.

Your session will take place at Angelia Claudette's private location, unless otherwise discussed. You will be sent the address upon completion of this form.

If you are an existing client, you will complete this form ahead of time to have a record of the progress happening in between your sessions. If you are a new client, you will complete this form to create your client profile.
Client Confidentiality and Privacy Rights
Your experiences during our sessions are confidential, and you have a right to view your client profile records upon written request. You can send an email request to info@angelia-claudette.com or give us a call at (202) 525-7817 for additional help.

Confidentiality is subject to the following exceptions:
- You instruct me to release information to other health care practitioners and/or other individuals, in writing.
- I am subpoenaed or otherwise legally obligated or reasonably allowed to do so (including circumstances where there is clear and imminent danger to yourself or another person).
- Your confidential client profile is kept in a secure location and is retained for 5 years after you end services, after which time all information will be destroyed in a proper manner.
- Your confidentiality is always subject to the usual exclusions dictated by state and federal laws and regulations.
I have read and understand the above disclosure regarding privacy policies and confidentiality, and that experiences during these sessions are confidential, but subject to the usual exceptions governed by laws of the State of Virginia and other federal laws and regulations.*

Clear
Scope of Care & Client Consent to Be Supported
Angelia Claudette provides certified integrative coaching services to support holistic, non-invasive, and non-toxic healing experiences.

I understand that Angelia Claudette is not a licensed physician, as her scope of care, at present, is unregulated and therefore, her services are not licensed by the state of Virginia. I understand it is my responsibility to maintain a relationship for myself with a medical doctor, mental health professional, or any other essential specialized health professional, if I so desire. I further understand that Angelia Claudette is not trained to diagnose illness, make recommendations involving pharmaceutical drugs or surgery, or handle medical emergencies. I also understand that the statements and services offered have not been evaluated by the US Food and Drug Administration.

I hereby release, waive, acquit and forever discharge Angelia Claudette Health + Wellness Coach and Angelia Claudette, any agents, successors, assigns, personal representatives, executors, heirs and employees from every claim, suit action, demand or right to compensation for damages I may claim to have or that I may have arising out of acts or omissions by myself or by Angelia Claudette, as a result of the recommendations given or otherwise resulting from any booked sessions. I further declare and represent that no promise, inducement or agreement not expressed in this agreement has been made to me to sign this agreement. This agreement shall bind my heirs, executors, personal representatives, successors, assigns, and agents.

Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless Angelia Claudette Health + Wellness Coach and Angelia Claudette, from and against any and all claims or liability of whatsoever kind or nature arising, out of or in connection with, my session(s).
By signing here I am stating that I have read, understand, and agree to the terms described above*

Clear
Your Personal Information
Legal Name*

First NameLast Name
Preferred Name

First NameLast Name
Phone Number*

Area CodePhone Number
E-mail*
Is this your first appointment with Angelia?*

YesNo

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you in a relationship?*
Religious/Spiritual Identification*
Gender Identification

FemaleMaleOther
Which describes your ideal health and wellness care?

AllopathicIntegrativeHolisticComplementary and Alternative (CAM)Other

Your Emergency Contact
Name*

First NameLast Name
E-mail
Phone Number*

Area CodePhone Number
Your Primary Care Physician
Name

First NameLast Name
E-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number

Brand Coaching Session
What is the name of your company?
What's your website URL?
How long have you been in business?

Less than 1 year1-3 years3-5 years5+ years
How is your business structured?

Sole ProprietorCorporationPartnershipOther
Describe your short-term and long-term goals.
What would you like to gain from this session?
In order for Angelia to get a full view of your lifestyle and how she may be able to gain more insight into your total well-being, please complete these surveys. (Take a screenshot or print to PDF your results and email to info@angelia-claudette.com)

Circle of Life

16 Personalities

Progress Update for Returning Clients
Last Appointment Date

MonthDayYear
If it has been longer than a year since your last appointment please describe your current health profile below and significant changes that have occurred in your health (i.e. getting pregnant, developing high blood pressure, significant weight loss, etc.)
Last Appointment Type

1 Hour Phone/Skype ConsultationWomb Sauna Session (Vaginal Steam) - with Thema Azize SerwaRitual Support ServiceVIP Small Business Mini-Coaching Session
What changes have you noticed and how did completing your regimen play a part in those changes?

Should be Empty:

	Very True	True	Somewhat True	Not True
I feel energetic and strong in my body
I do not experience chronic pain or discomfort
I am happy with my physical appearance
I get adequate rest and quality sleep

	Very True	True	Somewhat True	Not True
I am decisive
I maintain a consistent practice of mindfulness (i.e. meditation, prayer, chanting...)
I hear my thoughts clearly
I get adequate rest and quality sleep
I tend to mostly think positively

	Very True	True	Somewhat True	Not True
I trust myself
I am happy with my life
I feel safe and secure
Every day the world gets to see the real me
I experience balanced relationships
I give and receive love easily
I feel supported

	Very True	True	Somewhat True	Not True
I feel energetic and strong in my body
I do not experience chronic pain or discomfort
I am happy with my physical appearance
I have go to sleep easily
I stay asleep
I have a consistent fitness routine daily
I eat a well balanced diet

	Very True	True	Somewhat True	Not True
I feel connected to my womb
I have no abnormal growths in my womb
I feel empowered during my menstrual cycle
I am current and aware of my hormone levels
I feel confident sexually and safe
I feel flexible in my hips, buttocks, and pelvis
I do not procrastinate on my creative ideas
I feel well-nurtured

Client Profile Form

Client Confidentiality and Privacy Rights

Scope of Care & Client Consent to Be Supported

Your Personal Information

Your Emergency Contact

Your Primary Care Physician

Client Communication

Preparing for Your Session with Angelia

Private Coaching Session

1 on 1 Womb Sauna Session (or V-Spa Session)

Nutrition Session

Brand Coaching Session

Progress Update for Returning Clients