•  Client Intake Form

    Client Intake Form

    True vitality begins when we understand, nourish and honor our bodies natural rhythm and ability to heal. But when that rhythm is off, and nothing seems to be aiding restoration, how do we reach vitality? That’s what I am here to offer: the guidance and evidence-based support to help you reclaim vitality.
  • You are not broken!

  • This form is designed to give me a clear picture of your current health, lifestyle and goals. Hormones are so deeply interconnected with every system in our bodies, being able to see the whole picture will help me be able to uncover potential deficiencies, imbalances and create a personalized plan to support you in restoring vitality.

    The more you can tell me about your health, life history, and current struggles, the more I will be able to efficiently gather the resources to support you.

    Once I receive your form, I will take 24-48 hrs to review it in detail. During this time I will reach out to schedule our first session to go over your story, goals and next steps. 

    NOTE: If you are pregnant, please fill out the pregnancy intake form.

  • Health History & Evaluation :

    The more details you share the better I will be able to support you on your healing journey.
  • Restore Vitality Policy:

    As a hormone coach I primarily focus on hormone and metabolic health, however, each client is a whole person, not a set of symptoms and I firmly believe that true healing occurs when the body is approached as a whole. Healing is not only in dos and dont's. True and lasting vitality isn't found in quick fixes or extreme diets, or one-size-fits-all plans, but an intuitive process of tuning into what your individual body needs to thrive.

    As your health coach, I am here to help you find what your body needs to heal, to hold space for your growth, to offer guidance, support, and empower you on your healing journey in restoring vitality. Coaching relies on open honesty, and mutual respect. I do not guarantee any healing, results or cures, but rather offer evidence based information, and support.

    Progress can often be slow, even feel like a step back at times, but I am here to encourage you to keep taking steps. Sometimes the small shifts can bring bigger shifts in other areas. 

    Hormone imbalances, painful periods, missing cycles, cold hands and feet, infertility...these aren't just symptoms, they're our bodies way of communicating with us that there is something deeper going on that needs support.  

    I work with clients via email, text, phone and zoom. My life is primarily filled with mothering and farming, so I mostly work after hours. I aim to respond within 24 hrs, but in some cases it may take up to 48 hrs.

     

    Not Medical Advice:

    I, Tiana, am not a licensed practitioner, physician, psychologist or dietitian. Health coaching is not a substitute for medical diagnosis, treatment or recommendation. Consult your healthcare provider with any concerns regarding medical conditions or medications.

     

    Client Agreement:

    • I, the client, understands that Tiana, the coach, can not diagnose, treat, or cure any conditions or diseases. She can not prescribe medications or treatments.
    • I am fully responsible for my physical, emotional and mental well-being during and after coaching support. 
    • I understand that results are not guaranteed and Tiana is not responsible for any outcomes.
    • I will be open and communicative. If a session is scheduled, I will arrive on time, if cancellation is necessary, 24 hr notice is required. However, form of appointment can be changed, such as from a zoom call to live messaging.
    • All client services and information are confidential. Everything shared between coach and client remains private. Written consent must be given for any information to be shared, except in the incident of client being at risk of self harm or the harm of others. Disclosure is required by law.
    • In the case of an emergency, client will contact local healthcare providers first.
    • Payment must be made prior to a full coaching session.
    • No refunds.
    • I understand that either party may terminate coaching agreement with a written notice.

    By signing below, you acknowledge that you have read, understand, and agree to the terms and conditions outlined. And you voluntarily enter this coaching relationship.

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          Restore Vitality ConsultationThis includes a review summary of your intake form either via phone or email (your choice), aswell as simple suggestions to support you on your journey. For the full coaching you would need to purchase the month package. If you’d like to do a consultation before commitment, price is reduced from full package.
          $25.00
            
          Restore Vitality Coaching Security DepositWhile you can submit a form without payment, we will not be able to proceed forward without some commitment.
          $50.00
            
          Restore Vitality Weekly Coaching Pay in FullPrice is for 1 month. You have access to all I have to offer you.
          $250.00
            
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