Intake Form — Nutrition is Therapy

Name

First Name

Last Name

Referred By

Birthdate

YYYY

Phone

(###)

###

####

Email Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Occupation

Areas of Concern

Current Medications/Supplements being taken

Include dosage

What issues/concerns causes you to seek treatment? Please describe.

Do you have any specific goals with regard to your treatment?

Do you have any particular concerns/fears with regard to treatment?

Eating Patterns

Are you a vegetarian?

Yes

Have you ever been a vegetarian in the past?

Yes

Do you eat a low-fat diet?

Yes

Describe a typical day of eating

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.

I agree