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Initial Extensive Health Intake Form

As your coach, my job is not to “treat” or diagnose you, but to be your ally and your resource. When it comes to health and wellness issues I will help you discover steps you may choose to take towards greater health and higher levels of wellness. As your ally, I may refer you to medical, psychological, nutritional and other health-related services for more information and to seek any treatment in these areas. I can be a source of support and accountability, helping you to follow through. Please share with me information about your health and wellness so that I may more fully understand your health challenges and aspirations for higher levels of wellness. 

Your answers help me understand you better so that I can give you better support during the coaching program. The more I know about you and your health/lifestyle history the better. Please be sure to answer truthfully. The information you share with me is held strictly confidential!
What type of birth control are you currently using?
What symptoms do you experience before/during your period?
Do you suffer from any heart/blood related issues? (eg. high/low blood pressure, high cholesterol, anemia,...)
Do you suffer from any digestive system related issues? (Eg. gluten/lactose or other intolerances, constipation, diarrhea, irritable bowel syndrom, SIBO,...)
Do you suffer from any neurological issues? (Eg. anxiety, depression, dizziness,fainting, seizures,...
Do you suffer from any reproductive system issues? (Eg. PCOS, PMDD, STD, fibroids, cysts,..)
Do you suffer from any other health related issues?
How long is your average cycle?
How long is your average period bleed?

Lifestyle Questions

Let's take a look at your lifestyle. Again please answer truthfully. Make sure your answers reflect your current lifestyle not your past or ideal future one. This is important to truly make a change in your life.

Almost done, I promise :)

COACHING CLIENT AGREEMENT AND DISCLOSURE STATEMENT 

1. Name: Jasmin Caviezel Phone: 6087720813 

2. Office Name: Jalistic Menstrual Cycle Coaching 
 

As a certified womens coach and menstural health educator and coach, I am not licensed, certified or registered as a health care professional. I am not a licensed medical physician and do not diagnose, treat or prescribe remedies for the treatment of disease. The services I perform, whether in person, by email or online, are at all times restricted to complementary and alternative health care services.

 

Complementary & Alternative Health Services provided at Jalistic is the Menstrual Cycle Coaching Program and individual coaching sessions. The nature of the Complementary & Alternative Services for Coaching is: 

Menstrual Cycle Coaching: As a Menstrual Cycle Coach we support and guide you in reaching your goals and well life vision. Our job is to explore the lifestyle changes you want, facilitate a process of change and help you develop the tools you need, self-efficacy and internal motivation towards actualizing yours dreams. The coaching services are designed jointly with the client; together we will engage in direct and personal conversations. The client can count on the coach to be honest and straightforward in asking questions and making requests towards your goals. The coach relationship is professional and strictly confidential. Typical sessions are 60 minutes and held online. 

Potential Benefits: Menstrual Coaching provides support towards adapting a more cycle synced lifestyle. The client will understand the function of the menstrual cycle and how different lifestyle changes positively affect the cycle.

Potential Risks: As a coach we provide support towards reaching your goals and well life vision. You are fully responsible for your well-being during coaching including the choices and decisions you make towards your goals. Coaching should not be used to replace medical care. It is your responsibility to maintain a relationship with your doctor and seek treatment from a health care physician if you have a health problem. 

No Guarantees: No one can predict with certainty the results of the services provided. We do not offer guarantees concerning outcomes or promise specific results or outcomes. 

Alternatives: If you are uncomfortable with anything discussed during your session at ANY TIME, please inform the coach immediately and your concerns will be discussed with you. As your coach we are 100% committed to you being successful in having the life you want. If appropriate, we will refer you to an appropriate health care professional.

 

File Records: The original disclosure statement copy will be kept on file for at least two years after the last date of service. Your information is held strictly confidential. 

Recommendations: As my client, you should discuss any recommendations we provide with your Primary Care Physician, Obstetrician, Gynecologist, Oncologist, Cardiologist, Pediatrician, Pediatric Health Care Provider, or other Board-Certified Physician you see.

Termination Rights: You have the right to terminate your coaching program at any time. We have the right to terminate your program if we feel your needs would be best met at another practice or referral to a medical professional is necessary. We have the right to terminate your program immediately with any verbal or physical threat or abuse of any kind. 

Informed Consent: The term “informed consent” means that the potential risks, benefits and alternatives of our services have been explained to you. By signing below you are voluntarily consenting to our services and acknowledging receipt of our disclosure statement. 

I have read or had read to me the above disclosure statement. I understand the nature of the Complementary and Alternative Health Care services to be provided and had any questions answered to my satisfaction. 

I understand that Menstrual Cycle Coaching, a Complementary and Alternative Health Care Service, is not a licensed, certified or registered profession.

I understand the risks, benefits and alternatives to the coaching services provided. I understand that I am not being given a guarantee or being promised a specific result or outcome. I understand that Menstrual Cycle Coaching is a comprehensive process that may involve all areas of my life, including work, finances, health, relationships, educations and recreation. I acknowledge that deciding how to handle these issues and implement my choices is exclusively my responsibility. I understand Menstrual Cycle Coaching is a relationship I have with my coach that is designed to facilitate the development of personal, professional, and/or business goals and to develop and carry out a strategy/plan for achieving those goals. 

I understand that I am fully responsible for my well-being during my coaching session, including my choices and decisions. I understand that if I am uncomfortable at any time during a session, I will inform the coach immediately and my concerns and alternatives will be discussed with me. I am aware that I can choose to discontinue coaching at any time and that professional referrals will be given if necessary. 

I understand it is my responsibility to maintain a relationship for myself with a medical doctor. I understand these services are not intended to replace any medical services prescribed by my doctor 

I understand that Menstrual Cycle Coaching does not treat mental disorders as described by the American Psychiatric Association. I understand that coaching is not a substitute for counseling, psychotherapy, psychoanalysis, mental health care or substance abuse treatment, and I will not use it in place of any form of therapy. I promise that if I am currently in therapy or otherwise under the care of a mental health professional, that I have consulted with this person regarding the advisability of working with a Menstrual Cycle Coach and that this person is aware my decision to proceed with the coaching services. 

I understand that Menstrual Cycle Coaching is not to be used in lieu of professional advice. I will seek professional guidance for legal, medical, financial, business, spiritual, or other matters. I understand that all decisions in these areas are exclusively mine, and I acknowledge that my decisions and actions are my responsibility. 

I understand that information will be held as confidential unless I state otherwise, in writing, except as required by law. I understand that certain topics may be anonymously shared with other wellness coaching professionals for training or consultation purposes. 

I voluntarily consent to Menstrual Cycle Coaching, the Complementary and Alternative health care services that I have obtained through www.jalistic.com for myself and/or my child. 

Thanks for submitting!

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