Name *
Name
Date
Date
Phone *
Phone
Address
Address
Areas of Concern
Include dosage
Eating Patterns
Are you a vegetarian?
Have you ever been a vegetarian in the past?
Do you eat a low-fat diet?
Including beverages and time of meals
Informed Consent
I understand that Vonda Schaefer is a licensed Marriage and Family Therapist as well as a Nutritionist (the state of California does not license Nutritionists) who holds a degree in Nutrition as well as a certification in Neuronutrient Therapy. I understand that I am seeking services for Nutrition and not for Therapy.
By checking this box I am verifying that I have read and understand the information stated above. *