Client Information Form - DOC by M34fxMy

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									                               United States: 703-879-8264 Mexico: 415-102-1511
                                          Celena@nutritionheals.com

                        Online Nutritional Therapeutics Intake Form

Name                                                              Date

Address



Home #                                                            Work#

Email

Marital Status                                             Date of Birth

Primary reason for coming



Symptoms/Situations



Specific Diagnoses



Spiritual/Emotional Concerns



Current medications




        Please email me a recent photo of yourself, along with a detailed letter that
        includes the following:

        Current supplements and dosages, recent medical evaluations or blood work (unusual findings),
        current symptoms, current diet diary for two days, date of last hair test, current sleeping patterns,
        current exercise patterns, details about emotional or spiritual concerns, food cravings and
        patterns (coffee, sugar, junk food, diet soda, etc.) anything else you would like to share with me,
        dreams and desires.




                P.O. Box 3235 Merrifield, Virginia 22116                 Celena@nutritionheals.com
                       United States: 703-879-8264                         Mexico: 415-102-1511
                              Celena Hadlock, M.Ed., CNC, NAT
                             Nutritional Counselor and Natural Chef


                       Client Agreement and Disclaimer
I hereby consent, authorize and request Celena Hadlock, M.Ed., CNC, NAT to educate
me about foods, nutrition, and nutritional therapies which are available within a whole
foods and natural approach to healing. I agree to hold her free and harmless from any
claims or suits for damages related to such consultations.

I understand the following regarding our sessions:

Celena Hadlock is not a medical doctor, and therefore does not diagnose illnesses or
prescribe medicine.

Celena Hadlock may educate me and make me aware of specific nutritional
supplements available on the market; however, I use such supplements based on my
own judgment and at my discretion.

Celena Hadlock may educate me and make me aware of specific nutritional protocols
and programs, and I implement such protocols and programs based on my own
judgment and at my discretion.

If I decide to use far-infrared sauna therapy as part of my nutritional protocol, I hold
Celena Hadlock free from damages or suits related to the use of this therapeutic piece of
equipment. I understand that I use it at my own risk.

24 hours notice is required for cancellation of appointments to avoid a cancellation
charge.

I have read, understood and agree to the above statements.



Name                                                 Date


Signature




       P.O. Box 3235 Merrifield, Virginia 22116             Celena@nutritionheals.com
              United States: 703-879-8264                     Mexico: 415-102-1511
                                 Celena Hadlock, M.Ed., CNC, NAT
                                Nutritional Counselor and Natural Chef

Dear Nutritional Client:

Welcome to my practice! I admire you for choosing to heal your body temple. I would
like to cover a few practical issues as we begin our healing path together.

I choose from a few basic functional tests to determine your nutritional status, based on
your needs and case history. These functional tests include:

   1. Hair Mineral Analysis – Mineral status, heavy metals, biochemical patterns
   2. Stool Testing – Food Sensitivities and Intestinal Health
   3. Kinesiology for sub-clinical co-infections – when indicated

Based on case history, dietary review, and functional testing, I create a nutritional and
supplement program for you. I utilize high-quality, easy-to-absorb supplements, as well
as superfoods and vibrational herbal formulas. I will help you with recipes, menu
planning, and food preparation techniques. I recommend far-infrared sauna therapy for
detoxification when indicated.

My nutritional programs are much enhanced through structural healing at a deeper
leveI, as well as vice versa. Nutrition is an excellent tool in aiding the healing of the
bioenergetic fields at the DNA level. I invite you to consider completing the Regenetics
Method, a form of bioenergy healing through activating DNA. Visit the following links for
more information:

http://potentiation.net/Facilitators/chadlock.html

http://www.potentiation.net/page8.html


I am committed to helping you and coaching you through the healing process. I ask that
you make the same commitment to following the process to its completion – that is the
best way to get results and receive continuity of care.




          P.O. Box 3235 Merrifield, Virginia 22116             Celena@nutritionheals.com
                 United States: 703-879-8264                     Mexico: 415-102-1511
Fees:

Potentiation Session – Regenetics Method                                         $150

Articulation Session – Regenetics Method                                         $150
Hair Test plus: comprehensive initial intake, case history review,
evaluation, creation of nutritional program – emailed                            $225

Subsequent Hair Test plus follow-up program - emailed                            $140

Comprehensive initial intake, case history review, evaluation,
creation of nutritional program – emailed                                        $175

Follow-up program – emailed                                                    $100
                                                                                750
In-person consult in Mexico                                                   Pesos
                                                                               1200
Hair Test in Mexico                                                           Pesos


Instructions:
   1. Please email me the intake form and personal letter, along with a digital photo.
   2. Please email me the disclaimer form.


Questions:
The fastest way to reach me is via email. Please send your questions to
celena@nutritionheals.com. If you are experiencing a medical emergency you must
consult your primary care physician or proceed to the emergency room at the closest
hospital. If you feel that you need to set up a phone consult for extra healing support,
please let me know and we will make arrangements.


Thank You! I Am Delighted To Work With You!
Celena




          P.O. Box 3235 Merrifield, Virginia 22116      Celena@nutritionheals.com
                 United States: 703-879-8264              Mexico: 415-102-1511

								
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