Client Intake Form | ME Wellness

Client Intake & Consent Form – Michelle Eggink Wellness

First name

Last name

Pronouns

Phone

Address

Date of Birth

What brings you to this session?

Do you have any current health conditions or diagnoses (physical or mental)?

Are you currently taking any medications or supplements? Please list:

Have you worked with a wellness or meditation practitioner before? If yes, what types of practices have you tried?

What are you hoping to receive or experience by working with Michelle Eggink Wellness?

What are your top 3 current wellness priorities? (e.g., anxiety relief, better sleep, emotional resilience, physical healing)

How does stress typically show up in your body/mind?

Are you allergic to anything (e.g. certain essential oils, foods, teas, etc.)?

Is there anything else you feel is important to share with me about your mental, physical, or spiritual background?

By checking the boxes below, you acknowledge that you have read, understood, and agreed to the following terms regarding services provided by Michelle Eggink Wellness:

I understand that the services provided are for general wellness and personal development purposes only and do not constitute medical advice, diagnosis, or treatment.

I acknowledge that Michelle Eggink is not acting as a licensed medical provider, therapist, or counselor, and I will not use these sessions as a substitute for professional healthcare or mental health treatment.

I take full responsibility for my physical, emotional, and mental well-being during and after our sessions.

I understand that any suggestions, techniques, or practices offered are optional, and I am free to decline or discontinue participation at any time.

I agree to pay the mutually agreed upon session fee that will be confirmed prior to the session via email or text.

Signature

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