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Client Consent and Survey

Please answer the following questions to the best of your ability and include all relevant details that could help me better understand your lifestyle and assist you on your journey to feel your best!


Can't wait to work with you!

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Question 1 of 42

When is your birthday? 

Format: Month / Day / Year

Question 2 of 42

What is your occupation?

Question 3 of 42

Where do you live in the world?

Question 4 of 42

How often do you travel?

Question 5 of 42

Briefly describe your home/family life:

Question 6 of 42

What are the top 3 things you want to work on in your life?

Question 7 of 42

What are your biggest health challenges at the moment?

Question 8 of 42

What inner blocks do you think are holding you back from achieving your optimal health?

Question 9 of 42

What makes you feel stressed or worried?

Question 10 of 42

What are your biggest strengths and weaknesses?

Question 11 of 42

What do you typically procrastinate on in your life?

Question 12 of 42

List your typical daily routine:

Question 13 of 42

What techniques have you tried in the past that worked for you and made you feel better? What have you tried that did not work for you?

Question 14 of 42

Do you have people in your life that will support your journey to your most radiant self?

Question 15 of 42

If you had a magic wand, what one thing would you change immediately about your life?

Question 16 of 42

How committed are you to transforming yourself to achieve optimal health?

Question 17 of 42

What 3 main goals do you wish to focus on in our time working together?

Question 18 of 42

How do you want to feel in the next 6 months? Describe in detail.

Question 19 of 42

Have you ever worked with and had great results from a healer, coach, or medical practitioner before? Please describe your experience.

Question 20 of 42

If you have worked with a coach, healer or medical practitioner before, what were the things you liked and disliked about your collaboration?

Client Agreement

As a Wholistic client, there are responsibilities you must respect and adhere to in order to maximize your results and ensure your journey to feel your best is not compromised. Please agree to each of the following statements of responsibility and sign your consent to adhere to these expectations.

Question 22 of 42

I agree to show up on time and without distractions to our appointed monthly calls.

A

Yes

B

No

Question 23 of 42

I agree to give my best effort to adhere to Wholistic protocols before, during, and after the program.

A

Yes

B

No

Question 24 of 42

I agree to keep a positive focus on my ability to feel my best.

A

Yes

B

No

Question 25 of 42

I agree to take 100% responsibility for my own success.

A

Yes

B

No

Question 26 of 42

I agree to implement the protocols jointly decided upon during coaching calls.

A

Yes

B

No

Question 27 of 42

I agree be open, coachable, and ready to explore new ways of thinking or being on this journey.

A

Yes

B

No

Question 28 of 42

I understand there is no expectation to make up a coaching call if I do not cancel within the stipulated 24 hours before the start of the call.

A

Yes

B

No

Question 29 of 42

I agree to come to each call with total clarity about the goal and main area of focus for the call.

A

Yes

B

No

Question 30 of 42

I agree to abstain from alcohol and recreational drugs for the duration of our time working together unless explicitly addressed with me on a case by case basis (special occasion/wedding).

A

Yes

B

No

Question 31 of 42

I am fully committed and I’m in charge of my health and I will implement the advice given to me to the best of my abilities.

A

Yes

B

No

Question 32 of 42

I agree to disclose any psychiatric care or medications that are currently part of my regimen or arise at any point during our time working together.

A

Yes

B

No

Question 33 of 42

I agree to be fully transparent in my communication and respond to all messages within 48 hours.

A

Yes

B

No

Question 34 of 42

I agree to disclose any health issues, any family issues, and any changes or challenges that arise in my day to day life.

A

Yes

B

No

Question 35 of 42

I understand this service is not intended to be a substitute for my physician’s medical advice, diagnosis, or treatment. *Always consult with your medical treatment team (physician, psychiatrist, etc.) if you are suffering from a serious illness. I recommend that you combine my services with regular appointments with your primary medical practitioner.

A

Yes

B

No

Medical Disclaimer:

As part of our work with you, Wholistic, Inc. may review your medical records, lab tests/results and nutrition in order to make recommendations customized to your individual needs (*during one-on-one sessions in person or via Skype only). However, energy therapy is not meant as a substitute for medical or psychological diagnosis or treatment. No medical claims are made regarding these treatments, and Wholistic Inc. is not responsible for outcomes.

Wholistic, Inc. does not diagnose conditions, nor do we perform medical treatment, prescribe substances, or interfere with the treatment of a licensed medical professional. We strongly recommend you see a licensed physician or other licensed health care professional for any physical or psychological ailment whether it be acute or chronic that you may be suffering from or suspect that you may have, and make complementary healing part of a complete health care program.

You should consult with a healthcare professional before altering or discontinuing any current medications, treatment or care, starting any diet, exercise or supplementation program, or if you have or suspect you might have a health problem.

The United States Food and Drug Administration (“FDA”) has not evaluated any statement, claim, or representation made on or accessible from this page/website. Nor has the FDA evaluated any food, product or service mentioned on, or available from or through, this page/website. No food, product or service mentioned on, or available from or through this page/website is intended to diagnose, treat, cure or prevent disease.

To the fullest extent possible, Client indemnifies and holds harmless Coach for any and all damages as a result of Coach’s advice, comments, or coaching techniques except for conduct constituting gross negligence.

Termination:

Coach may terminate or suspend Coaching services immediately, without prior notice or liability, for any reason whatsoever, including without limitation if you breach the Terms.

All provisions of the Terms which by their nature should survive termination shall survive termination, including, without limitation, the warranty disclaimers, indemnity and limitations of liability.

Cancellation Policy:

24 hour notice is required when changing or canceling an appointment. If an appointment is missed or cancelled without a 24 hour notice, the full appointment fee will be charged.

Coach shall have no responsibility or expectation to make up any cancelled coaching call if Client does provide the required 24 hour notice.

Governing Law:

These Terms shall be governed and construed in accordance with the laws of Florida, United States, without regard to its conflict of law provisions.

Our failure to enforce any right or provision of these Terms will not be considered a waiver of those rights. If any provision of these Terms is held to be invalid or unenforceable by a court, the remaining provisions of these Terms will remain in effect. These Terms constitute the entire agreement between us regarding our Service, and supersede and replace any prior agreements we might have between us regarding the Service.

Changes:

We reserve the right, at our sole discretion, to modify or replace these Terms at any time. If a revision is material we will try to provide at least 30 days notice prior to any new terms taking effect. What constitutes a material change will be determined at our sole discretion.

By continuing to use our Service after those revisions become effective, you agree to be bound by the revised terms. If you do not agree to the new terms, please stop using the Service.

Question 41 of 42

Please upload a photo of yourself. Make sure you are alone in the picture, standing straight, and fully clothed with your full-body visible in good lighting.

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You agree to the terms of this agreement and agree that your typed full name can be used as a digital representation of your signature to that fact.

Please Click Next to Accept the Agreement, and Enter Your Name and Email, thank you!

Confirm and Submit