Client Initial Intake/ Consent

Client Intake / Informed Consent Acknowledgement

I am filling out this form for: *

Myself as client Minor child who I am legally allowed to sign electronic consent for As a practitioner filling it out ON BEHALF of my client. I will upload a hard copy of my client's consent for bioenergetic assessment Other: you will be required to submit by email a hard copy of the client consent

* Indicates required field

Name *

First

Last

City, State, Zip (do NOT include physical/mailing address details) *

Date of Birth *

Name of Practitioner Referring You *

Practitioner's Office Name *

What Are Your Top 3 Health Concerns *

If you are experiencing any symptoms, what are they? *

List any Past or Present Medical Diagnosis you have received from a Licensed Medical Provider *

List Any Past Surgeries You Have Had *

List Any Supplements You are On *

Height and Weight *

List any Prescription Meds You are on *

How many ounces of Water do you drink in a day? *

What type of Water Do you Drink *

How many bowel movements do you have per day or per week (please specificy if it is per day or per week) *

What time do you go to bed? *

What time do you wake up? *

Do you Sleep all night? *

On a Scale of 1-10 what is your overall stress level? Marriage, Work, Kids, Finances, Parents/InLaws *

Tell Us About your Beverage Intake: Specifically Coffee, Alcohol, and Soda. How many times a week, how many ounces of each *

Do you have any dental fillings, caps, crowns, implants etc. If yes please share what type *

Females: What Birth Control Do You Use? *

Breifly Share with Us if You have any history of Trauma. We do not need specific details. *

I do not know my genetic variants or SNPs but I would like to learn more info on how/where to order that test *

yes no

I am *

If you have had genetic testing for MTHFR and SNPS and know your gene variants please list them below *

I am OK with Homeopathic Remedies in an Alcohol Base *

READ IN FULL HERE Consent Form

I AFFIRM I HAVE READ IN FULL THE INFORMED CONSENT AND DISCLOSURE STATMENT PROVIDED IN THE LINK DIRECTLY ABOVE AND CONSENT FOR BIOENERGETIC SERVICES THROUGH THE PRACTITIONER I NAMED ABOVE. *

yes

TYPE YOUR FULL NAME IN THE TEXT BOX PROVIDED BELOW. THIS WILL SERVE AS YOUR ELECTRONIC SIGNATURE IN SUBMITTING THE INTAKE AND CONSENT EFFECTIVE ON THE DATE OF SUBMISSION. TYPE IN YOUR NAME if you are not the client who is consenting. Only the client or their legal representative (POA, guardian, etc) may give consent. If you are someone else, please email a hard copy of the client's consent to info@bioenergeticanalysisresources.com *

I am OK with POWDERED Supplements *

I am OK with swallowing Pills *

Tell us about your saliva swab (biological sample) *

My practitioner is sending to you I am sending it to you, please watch for it I am ok to proceed with the assessment without a biological sample

Mailing address for SALIVA SWAB if you or your practitioner are sending one. Please swab the inside of your cheek with a clean cotton swab (a q-tip is fine) and place in a ziploc bag with
1. your name
2. your practitioner name/office name
3. PRACTITIONER EMAIL (NEW!!! Please include on ziploc bag or envelope)
4. your (client) date of birth.

Practitioners: we will now be notifying you by EMAIL when your client sample has arrived at the home office for testing.

BAR, LLC

2810 Swanson Road
Nekoosa WI 54457
United States

UPDATE: Biological samples are not required at this time if you wish, we will work off your energetic signature of your name, date of birth and location in the world. If you would like to send a biological sample you may send your choice of a saliva swab, a hair sample, or nail clippings, but it is not required.

​Client Intake / Informed Consent Acknowledgement

Client Intake / Informed Consent Acknowledgement