Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 3Name *FirstLastDate of Birth *GenderMaleFemaleTransgender MaleTransgender FemaleUnspecifiedEmail *Optional: Upload a photo of yourself. Click or drag a file to this area to upload. Mobile number *What do you hope to achieve in our sessions together?NextIf applicable, please list any current or past medical conditions in your health history. ConditionCurrent treatment(s) for this conditionCondition (2)Current treatment(s) for this conditionCondition (3)Current treatment(s) for this conditionCondition (4)Current treatment(s) for this conditionCurrent medications and/or supplementsCurrent MedicationsNoneAtorvastatinLevothyroxineLisinoprilMetforminMetoprololAmlodipineAlbuterolOmeprazoleLosartanGabapentinHydrochlorothiazideSertralineSimvastatinMontelukastAcetaminophen; HydrocodonePantoprazoleFurosemideFluticasoneEscitalopramFluoxetineRosuvastatinBupropionAmoxicillinDextroamphetamine; Dextroamphetamine Saccharate; Amphetamine; Amphetamine AspartateTrazodoneDuloxetinePrednisoneTamsulosinIbuprofenCitalopramMeloxicamPravastatinCarvedilolPotassiumTramadolClopidogrelInsulin GlargineAspirinAtenololVenlafaxineAlprazolamEthinyl Estradiol; NorethindroneAllopurinolHydrochlorothiazide; LisinoprilCyclobenzaprineClonazepamZolpidemAzithromycinOxycodoneWarfarinMethylphenidateApixabanRanitidineGlipizideErgocalciferolQuetiapineBudesonide; FormoterolEstradiolAcetaminophen; OxycodoneOndansetronNaproxenGlimepirideSpironolactoneClonidineInsulin LisproLoratadineCetirizineTopiramateLorazepamEthinyl Estradiol; NorgestimateLamotrigineDiltiazemHydrochlorothiazide; LosartanDiclofenacHydroxyzineBuspironeLatanoprostParoxetineLisdexamfetamineFluticasone; SalmeterolPregabalinPropranololCephalexinCholecalciferolInsulin AspartFinasterideFenofibrateSitagliptinFolic AcidDoxycyclineRivaroxabanTizanidineAmoxicillin; ClavulanateAmitriptylineLovastatinAlendronateLevetiracetamSumatriptanHydralazineSulfamethoxazole; TrimethoprimAripiprazoleCelecoxibFerrous SulfateFamotidineBenzonatateMirtazapineTriamcinoloneEzetimibeFluticasone; VilanterolValacyclovirMethotrexateOxybutyninCiprofloxacinValproateTriamterene; HydrochlorothiazideThyroidDiazepamNifedipineClindamycinDonepezilInsulin DetemirHydroxychloroquineIsosorbideEthinyl Estradiol; LevonorgestrelBaclofenTestosteroneEsomeprazoleDesogestrel; Ethinyl EstradiolOseltamivirBenazeprilDexmethylphenidateTiotropiumFluconazoleDulaglutideChlorthalidoneMethocarbamolEnalaprilMetronidazolePrednisoloneGuanfacineVerapamilLiraglutideNorethindroneRopiniroleAcetaminophenEmpagliflozinHydrocortisoneDrospirenone; Ethinyl EstradiolRisperidoneMeclizineAlbuterol; IpratropiumAdalimumabNortriptylineValsartanCyanocobalaminEtonogestrel; Ethinyl EstradiolAcyclovirPhentermineCefdinirTimololMethylprednisoloneOxcarbazepineMorphineOlmesartanDicyclominePramipexoleAzelastineInsulin DegludecMemantinePrazosinKetoconazoleRizatriptanAcetaminophen; CodeinePromethazineMetformin; SitagliptinAnastrozoleDesvenlafaxineRamiprilPioglitazoneClobetasolIrbesartanLevofloxacinAmiodaroneNitroglycerinOlanzapineSucralfateDocusateProgesteroneMirabegronMupirocinNebivololNitrofurantoinLevocetirizineMethimazoleCyclosporineSildenafilCarbamazepineLabetalolCalcium; CholecalciferolLansoprazoleBudesonideColchicineTerazosinUmeclidinium; VilanterolLithiumDigoxinDorzolamide; TimololMelatoninInsulin Human; Insulin Isophane HumanDoxazosinRanolazineGemfibrozilAmlodipine; BenazeprilTemazepamFlecainideTicagrelorBrimonidineDexlansoprazoleLidocaineLurasidoneBenztropineNystatinEszopicloneSacubitril; ValsartanCalcium CitrateSodiumTorsemideButalbital; Acetaminophen; CaffeineMesalamineLiothyronineBuprenorphineOfloxacinErythromycinDoxepinSemaglutideHydromorphonePenicillin VValsartan; HydrochlorothiazideBeclomethasoneBrimonidine; TimololBumetanideLetrozoleLinagliptinTretinoinMinocyclineIpratropiumPolyethylene Glycol 3350UmeclidiniumBisoprololCalcitriolVareniclineEpinephrineEstrogens, ConjugatedGlyburideGuaifenesinMagnesium AcetateEthinyl Estradiol; NorgestrelSotalolBimatoprostInsulin IsophaneMedroxyprogesteroneTamoxifenMometasoneSulfasalazineDorzolamideKetorolacIndomethacinAtomoxetineOlopatadineTelmisartanPhenytoinBuprenorphine; NaloxoneRaloxifeneTobramycin; DexamethasoneNaltrexonePolymyxin B; TrimethoprimTerbinafineFentanylDiphenhydramineBisoprolol; HydrochlorothiazidePancrelipase Lipase; Pancrelipase Protease; Pancrelipase AmylaseZonisamideFexofenadineErenumabLinaclotideBrompheniramine; Dextromethorphan; PseudoephedrineOmega-3-acid Ethyl EstersDimethylTadalafilCanagliflozinEmtricitabine; Tenofovir DisoproxilTolterodineEtanerceptQuinaprilSenna; DocusateBetamethasoneSolifenacinInsulinChlorhexidineFluocinonideNextRescheduling and cancellationsYou may reschedule appointments without penalty so long as you give 24 hour notice. Unless you have a legitimate emergency, I'm not able to issue credit for a last-minute cancellation. Consent for servicesAll services require payment at the time they are delivered. Insurance co-payments and deductibles, if accepted and applicable, must be paid at the time of service. Please check each box below to affirm your consent:Please check the boxes to indicate your acceptance:I understand that the coaching services I will be receiving under this agreement are not offered as a substitute for mental health care and are not psychological or medical care services. I also understand that my Coach is not acting as a mental health practitioner or as a licensed physician and does not purport to offer mental or other kinds of medical care. If my Coach believes that medical care services may be helpful, my Coach may provide a referral.I understand and agree that I am fully responsible for my well-being during my coaching calls, and subsequently, including my choices and decisions.I understand that I must discuss any confidential documentation I wish to share with my Coach prior to the sharing of that information, as the Company may require additional waivers of liability.All services require payment at the time they are delivered. The corresponding co-payments and deductibles for insurance, if accepted and applicable, must be paid at the time of service.SignatureClear SignatureSubmit