New Client Form
Questionnaire #3
Please write 0-10, with 0 being never and 10 being always
Make sure to hit submit after each section.
Natural health methods to balance the body and reduce symptoms can take time. Often we liken it to peeling an onion. The process can feel like one layer at a time, but the sticking to the plan is worth the effort and wait.
Make sure to hit submit after each section.
Symptom Questionnaire
Make sure to hit submit after each section.
Questionnaire #1
Anxiety Questionnaire
Questionnaire #2
Food Journal
Make sure to hit submit after each section.
Timeline of Life
Medications and Supplements
Informed Consent Statement
I hereby attest and agree to the following:
1. I fully understand that Lylyan Nobles is a lay natural health ADVISOR and TEACHER who deals strictly in helping people to improve their general health and fitness through better nutrition, improved lifestyle and health habits.
2. I fully understand that Lylyan Nobles is NOT a licensed physician and cannot diagnose diseases, prescribe drugs or recommend treatments for specific disease conditions.
3. I understand that all evaluations performed by Lylyan Nobles and her representatives are designed to evaluate my inherent constitution and temperament for the sole purpose of helping me to improve my general health through nutrition, habits and attitudes. I further understand that said evaluations cannot determine specific disease conditions I may have and do not replace the diagnostic services offered by licensed physicians.
4. I understand that Lylyan Nobles neither claims nor implies that any instruction, advice, counsel, suggestions, recommendations, services or products she or her representatives provide, whether in person or by mail or by telephone, will cure, treat, prevent or mitigate any disease condition; but are provided solely for the purpose of increasing energy, supporting the natural function of body systems and otherwise improving general health and fitness.
5. I understand that Lylyan Nobles and her representatives will not suggest that I cease any medical care I may be currently undertaking. I understand that the decisions I make regarding my health care and the health care of those under my guardianship are my responsibility and certify that I will not hold Lylyan Nobles or her representatives responsible for the consequences of my decisions.
6. I understand that Lylyan Nobles believes that genuine healing comes only from God and that God has provided simple and natural methods such as rest, nutrition, herbs, exercise, attitude changes and touch to help people recover and maintain their health. I further understand that Lylyan Nobles shares these methods with others as part of her God-given and constitutional rights of freedom of speech and freedom of religion.
7. I have received a copy of Lylyan Nobles’ Disclosure Statement and access to the Schedule of Fees on her website. With this understanding, I desire to consult with her on my health needs.
I have read and understand the foregoing and agree to the terms and conditions set therein. I have received a copy of this agreement.
Dated _____________________, 20__
You will be given a physical copy to sign and one to keep at your appointment
Client Signature Print Client Name above