New Client Intake Form

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*

MM

DD

YYYY

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.

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:

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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