Client Intake

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What is your name?* This field is required.
First Name
Last Name
2
What is your birth date: year, month, day?* This field is required.
Year/Month/Day
3
What is your gender?* This field is required.
4
What is your email address?* This field is required.
example@example.com
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What is your phone number?* This field is required.
Area Code
Phone Number
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How would you prefer me to contact you?* This field is required.
Email
Text
Phone
7
Were you referred or a member/client of any of the following establishments?* This field is required.
Naturopathic referral
CLGS
Zen Fitness member/client
New Client/ None of the Above/From the Roots Holistic Client
8
What service are you registering for?* This field is required.
Meal Plan
One on One Consult
General Consult, 30 minutes
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What service are you registering for?* This field is required.
General Consult, 30 minutes
Body Composition measurements
Detox
Foundations to Wellness
One on One Consulting
Zen Wellness
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What service are you registering for? * This field is required.
General Consult, 30 minutes
Body Composition measurements
Detox
Foundations to Wellness
One on One Consulting
Metamorphosis into Wellness
Zen Wellness
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Where would you like to have your appointment* This field is required.
In-person (downtown office)
Remotely via online video chat
Remotely via phone
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What question(s) would you like addressed during your consult?* This field is required.
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Will you be doing this program with a friend/family member?* This field is required.
Yes (be sure to have them register as well)
No
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What is your friends/family members name?* This field is required.Be sure to have them fill out this form as well.
First Name
Last Name
15
Would you like to add on any extra services to compliment your program?
Cooking class
Nutritionist guided shopping trip
Detox
Follow up mini sessions
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How many mini sessions would you like to include?
15 minutes each
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Where would you like to have your sessions?* This field is required.
Held online via Facebook, Hangouts, or Skype
Over the phone
In person at my office
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What Detox session are you registering for?* This field is required.
Private one on one (starts anytime)
January 13, 2020
March 9, 2020
May 18, 2020
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Which Detox level are you registering for?* This field is required.
Beginner's (14 days)
Intermediate (14 days)
Advanced (21 days)
To find out what each level consist of please visit my website here https://www.fromtherootsholistic.ca/detox-with-a-nutritionist.html
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The Advance program requires supplements & botanicals remedies. You have the option to purchase the required supplements on your own, however please be advised that the supplements have to be the specific brand name listed and are needed for the detox. If you would like to order through me please choose which supplements & botanicals you would like, this will be added to your base fee of $100.00. All prices include taxes. LIMITED QUANTITIES IN STOCK FIRST COME FIRST SERVE.
2 bottles of Liver Health Tincture, Orange Naturals $35.40 (average retail price for 2 bottles is $43.98- $47.98 in Health Food stores)
Bulklax® , St-Francis Herb Farm $17.94 (average retail price is approx. $22.95 in Health Food stores)
Oréganum Plus® 1:3, St-Francis Herb Farm $11.94 (average retail price is approx. $16.94 in health food stores)
Oréganum Plus® Gel Caps, St-Francis Herb Farm $16.74 (recommended for those who can't tolerate the taste of oregano oil, average retail price is approx. $22.99 in Health Food stores)
Probiotics, CanPrev, $22.12 (average retail price is approx. $25.99-$29.99 in Health Food stores)
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How tall are you?* This field is required.Please indicate your height in inches.
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How much do you weigh?* This field is required.Please indicate your weight in pounds
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Physical Activity Level (Please read closely)

Sedentary:

Active job (4 hrs or less) + working out less than the Low Active Leve + household chores

Sedentary job + working out less than the Low Active + household chores

Low Active:

Active job (8 hrs) + working out gently (yoga) 3-4 days a week + household chores

Sedentary job + working out 5 days or more a week for a minimum of 60 minutes (resistance & cardio) + household chores

Active:

Active job (8 hrs) + working out working 5 days a week for a minimum of 60 minutes (resistance & cardio) + household chores

Very Active:

Professional athlete

Personal trainer (8hrs or more training hands-on)
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Based on the description you just read what is your physical activity level?* This field is required.Please be honest this is used to calculate your caloric range.
Sedentary
Low Active
Active
Very Active
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Please describe in detail the reason why you need a meal plan and any important details such as dislikes or other issues that may come into play when I create your meal plan.
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Health Concerns and or goals: List goals or health imbalances you would like to work on?* This field is required.Please be sure they are relevant to the service or program you have registered for.
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List all medications, including supplements, sports supplements, herbal remedies, birth control, IUD's....
If you are booking in for One on One consulting please bring in your supplements so I can go over the labels.
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Have you had any recent concerning medical test or have you had any recent surgeries?
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If you have any allergies or sensitivities please list them below.
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If you were referred by a Naturopath please be sure to indicate the Naturopath in the next section.
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Please let me know what Health Practitioners are part of your health team?
First Name
Last Name
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Please indicate what type of Health Practitioner they are?
Other
Other
Family Physician
Nurse Practitioner
Chiropractor
Naturopath
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Are there any other Health Practitioners involved in your wellness?
YESNO
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What is the Health Practitioners name?
First Name
Last Name
35
Please indicate what type of Health Practitioner they are?
Other
Other
Family Physician
Nurse Practitioner
Chiropractor
Naturopath
36
Are there any other Health Practitioners involved in your wellness?
YESNO
37
What is the Health Practitioners name?
First Name
Last Name
38
Please indicate what type of Health Practitioner they are?
Other
Other
Family Physician
Nurse Practitioner
Chiropractor
Naturopath
39
Are you filling out this form for a minor or someone who requires a legal guardian?* This field is required.
No
Yes
40
If yes what is your relationship to the minor or individual?* This field is required.
Legal guardian
Parent
Other
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What is your name* This field is required.
First Name
Last Name
42
Appointment/Program Terms & Conditions (please read)

All information provided in this form and going forward is confidential and will not be released to anyone.

Individuals seeking One on One Consulting (in-person or online) will be booked in for two initial appointments. One health & lifestyle assessment and one overview appointment. The fee for both appointments is a packaged fee to be paid at the first appointment.

Individuals seeking “general consulting” understand that this is a general consult for general nutrition/supplement/botanical remedy questions and will not address disease-specific questions or go into detailed personalized advice. Those who would like personalized and/or disease-specific consulting should register for the One on One Consulting where a full assessment can be taken.

Body Composition Measurements are not recommended for individuals who have a history of Body Dysmorphic Disorder(s).

Individuals seeking meal plans understand that meal plans are designed for your unique needs and have to be followed in order for them to be effective and to assure all nutritional needs and caloric needs are being met. It is the responsibility of the client to inform Dana of all the details required in this intake form and during any appointments (if an appointment is needed) truthfully and accurately so Dana can properly formulate a meal plan. Should you not implement or fully implement the meal plan Dana Clark/From the Roots Holistic is not liable for any negative health outcomes or lack of benefit. Meal plans are based on your requirements and Dana's formal Academic training.

A formal Consulting & Privacy Agreement will be provided during your first session for you to sign. Online consults, you will receive a digital copy, it must be officially or digitally signed, typed in signatures are not acceptable.

For Health Benefit Claims, you are encouraged to inquire and confirm that you are covered for my services (Registered Nutritional Consultant and/or Certified Natural Health Practitioner) and to submit receipts to your insurance company.

For online sessions, it is recommended you avoid using mobile data & satellite connections as they don’t provide the quality connection needed for video calls.

Once your appointment is booked, it is your responsibility to attend this appointment and any future appointments or cancel within 24 hrs. No-shows will be billed $10 for not canceling the appointment(s). Please arrive on time for appointments, should you arrive late your appointment will still end at its original intended time.

Payment plans are available for the Foundations to Wellness, Zen Wellness, and Metamorphosis programs, a down payment of $100 is required as well as a credit card on file. Should you drop out of any program at any time all payment must be honored and the full payment paid.

All fees are none refundable.
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By signing this form you are agreeing to all the Appointment/Program Terms & Conditions
Clear
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How would you like to pay for your appointment or program?* This field is required.
Cash (for in person appointments only, please bring the exact amount)
E-transfer to fromtherootsholistic@gmail.com
Credit card
Payment Plan for either Foundations to Wellness, Zen Wellness, Metamorphosis
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Do you have a coupon code to apply to a wellness program? If yes please enter it below.
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Do you require a formal receipt to submit to any Health Benefits Coverage Plan?* This field is required.
yes
no
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