Intake Form

Step 1 of 6

Introduction
Date
Date of Birth/Age
Name
Pronouns
Height
Sex
Weight

Lifestyle
Do you participate in any exercise programs? If yes, how long have you been exercising? How often?
Do you vacation regularly?
When was your last vacation?
Do you participate in spiritual discipline? (religious group, meditation, church etc)
What level of stress do you feel you are experiencing at this time?
What are the major causes of your stress? (check all that apply)
If other, please specify
How does your stress manifest itself?
Do you use any coping mechanism for your stress?
What time do you go to sleep and wake up?
How many hours do you sleep?
Do you awaken feeling rested?
How many hours do you spend daily, on average:
Driving Watching Tv Reading In front of computer
What are your interests and/or hobbies?
How satisfied are you with: rank 1-5 (1=very dissatisfied, 5=very satisfied)
Eating Habits Stress Management Fitness and exercise habits Weight/Body composition Sleep Habits Overall Health Body Image and self esteem Energy levels Bowel Movements
Privacy Disclosure: All information collected for registration will be kept on file for identification and for Audra Bursae to contact the individual named. These files are confidential. Any new client seeking the services of Audra Bursae is required to fill in and sign this form before any services are performed. If the individual named below is sending a digital copy of this form, checking the checkbox next to the signature line is considered a digital signature. This form is to be filed and kept for insurance purposes*
Privacy Disclosure: All information collected for registration will be kept on file for identification and for Audra Bursae to contact the individual named. These files are confidential. Any new client seeking the services of Audra Bursae is required to fill in and sign this form before any services are performed. If the individual named below is sending a digital copy of this form, checking the checkbox next to the signature line is considered a digital signature. This form is to be filed and kept for insurance purposes
- Yes
Release: “I hereby release Audra Bursae and Nourish Mind + Body, LLC. from all claims of damages arising from any accident or injury which is caused by or arises from participation of the applicant named herein, during any program, any class or any therapy or any location where a program or therapy is held. I understand and acknowledge that the services provided are at all times restricted to consultation on the subject of health matters intended for general well-being, and are not meant for the purposes of medical diagnosis, treatment or prescribing of medicine for any disease, or any licensed or controlled act which may constitute the practice of medicine. This statement is being signed voluntarily.”*
Release: “I hereby release Audra Bursae and Nourish Mind + Body, LLC. from all claims of damages arising from any accident or injury which is caused by or arises from participation of the applicant named herein, during any program, any class or any therapy or any location where a program or therapy is held. I understand and acknowledge that the services provided are at all times restricted to consultation on the subject of health matters intended for general well-being, and are not meant for the purposes of medical diagnosis, treatment or prescribing of medicine for any disease, or any licensed or controlled act which may constitute the practice of medicine. This statement is being signed voluntarily.”
- Yes
Cancellation Policy: Once purchased, your packages and services with Nourish Mind + Body, LLC. are non-refundable. Please note that 24 hours notice must be given to cancel or rebook appointments. If 24 hours notice is not given, 100% of your consultation fee will be applied to the missed appointment.*
Cancellation Policy: Once purchased, your packages and services with Nourish Mind + Body, LLC. are non-refundable. Please note that 24 hours notice must be given to cancel or rebook appointments. If 24 hours notice is not given, 100% of your consultation fee will be applied to the missed appointment.
- Yes
Date
MM slash DD slash YYYY
Name
First Last
Signature
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone (home)
Phone (cell)
Email