New Client Intake Form • Teri Cochrane

Please complete and submit form after you have scheduled your appointment. To schedule an appointment, please fill out the contact form.

Required fields noted with an asterisk (*).

Step 1 of 7

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Enter Email Confirm Email
Cell Phone*
Home Phone
Birthdate*
Month
Day
Year
Client is a*
- Male
- Female
- Child
Child resides with
- Mother
- Father
- Both
Weight*
Please enter a number greater than or equal to 1.
Height*
Age*
Occupation*
How did you hear about us?*
DISCLAIMER

The advice and opinions provided by Teri Cochrane and/or her staff are based on their education, training and experience. Teri Cochrane and/or her staff, Teri Cochrane S LLC, Healing Paths LLC DBA Teri Cochrane - Beyond Nutrition expressly disclaim all responsibility for any liability, loss, claim, damage or risk, personal or otherwise, which may be incurred as a result of any recommendation for any dietary or lifestyle change, including the use of dietary supplements. Bio-individualized nutritional counseling is not intended as medical advice, nor should it be used as a substitute for medical care administered by a physician or other licensed health care provider.

Upon your request, our office may provide you with a nutritional genomic review based on genetic data provided by you. The jurisdiction for this analysis will be under the laws of the state of Virginia. Please contact a licensed genetic counselor or other licensed healthcare professional for health-related genetic advice.

Any and all appointments and interactions with Teri Cochrane and/or her staff, Teri Cochrane—Beyond Nutrition or Healing Paths LLC are on an at-will basis, and either party may terminate the professional consulting relationship at any time. During the course of your appointment, Teri Cochrane and/or other nutritional professionals may touch you with gentle pressure to perform proprietary muscle testing using applied kinesiology. Our methodology has not been evaluated by the Food and Drug Administration. Our program and the individual counseling services provided are not intended to diagnose, treat, cure, or prevent any disease. Before making any complex health-related decisions, please consult your physician or other licensed healthcare provider.

We are committed to maintaining client confidentiality and protecting the security of personal information you provide to us by following industry best practices for internet security. We are not required to and currently do not operate under federal Health Insurance Portability and Accountability Act (HIPAA) compliance standards.

Policies, Procedures and Fees
Health Insurance Claims

As we are not a medical practice, we do not participate or coordinate with any health insurers. If your insurance (including Flexible Spending Account or similar program) covers services and/or supplements such as those provided by our office, please work with your primary care provider directly to assist you with filing insurance claims.

Appointment Cancellation and Fees
- We require a $175 deposit at the time of booking to secure a new client initial consultation.
- We will confirm your appointment one week and again two (2) days before the date of service via text messages and phone.
- If you are unable to make your Initial Consultation and do not notify our office at least two (2) business days in advance of your appointment, we will retain your $175 deposit as a “No Show Fee.” In the case of Follow-up appointments, you will be assessed a cancellation fee of $100 to the credit card on file.
- Please contact the office at 703-435-8193 or [email protected] to make, change or cancel an appointment
Late Arrival for Consultations
- To preserve the quality of our care for you and in consideration to our other clients, if you do not arrive within 15 minutes of your scheduled appointment time, we regret that you may not be able to be seen that day and you will be assessed a cancellation fee of $100.
- Privacy Policy
- Terms of Service
Acknowledge Terms*
By completing and submitting this form and providing your electronic signature, you acknowledge and agree to the above Disclaimer as well as our Policies, Procedures and Fees; Privacy Policy and Terms of Service:

Reason for Visit to Teri Cochrane*
How long have you had these conditions?
Have you received medical treatment for these conditions?
- Yes
- No
What treatment have you received for these conditions?
Other medical conditions
Past medical conditions or recurring infections
Blood Tests
Date of Last Physical Exam
MM slash DD slash YYYY
Total Cholesterol
LDL
HDL
Triglycerides
TSH

Thyroid Stimulating Hormone
T3

Triiodothyronine
ALT/AST
Blood Pressure
Fasting Glucose or HA1c
Current Medications / Supplements, including Herbal and OTC Medications
Type & Dosage
Date Started
MM slash DD slash YYYY
Type & Dosage
Date Started
MM slash DD slash YYYY
Type & Dosage
Date Started
MM slash DD slash YYYY
Type & Dosage
Date Started
MM slash DD slash YYYY
Type & Dosage
Date Started
MM slash DD slash YYYY
Type & Dosage
Date Started
MM slash DD slash YYYY

Step 1 of 7

Policies, Procedures and Fees

Blood Tests

Current Medications / Supplements, including Herbal and OTC Medications

History

Have you or any of your family members experienced any of the following conditions?

Check the boxes if the statements below apply to you.

Mother’s Pregnancy

Pregnancy

Child History

CURRENT HISTORY

Gas/GI

Kidneys

Neurological Function

Adrenals

Endocrine

Liver

Thyroid

Allergies

Growth and Skin

Vaccinations

Sleeping Patterns

Neurological

Other

Food Habits:

Mind Body