For efficiency, please fill out appropriate forms before your appointment plus Informed Consent
*Holistic Intake Form
Follow up visits:
*Metabolic Analysis Intake- females
*Metabolic Analysis Intake - males
Instructed to find a particular form for re-evaluation, an arranged assessment or a family plan?
1. I hereby authorize Connection 2 Health and all representatives to act on my behalf concerning the corrective, therapeutic, natural, non-drug, non-evasive protocols offered to achieve health. I specifically authorize for my health to be evaluated based on holistic concepts and for the appropriate nutritional and detoxification protocols, lifestyle, and environmental modifications to be recommended.
2. I warrant that all information submitted for analysis and evaluation was submitted by me and is true to the best of my knowledge.
3. I understand I am not attending an allopathic doctor (MD), but a Certified Traditional Naturopath (CTN) and Biofeedback Specialist (CBS), and most of all, your wellness advocate!
4. I understand that I will not receive allopathic drugs, surgery, chemical stimulants, or any other allopathic treatments. I understand the programs recommended are in no way to take the place of traditional medical treatment and if I desire further information or services not provided I will seek them elsewhere.
5. Connection 2 Health is available to work with my medical doctor or any other health care provider to implement a program of integrative wellness.
6. All information disclosed will be kept confidential except under the circumstances of law enforcement requirements.
7. The programs recommended are to promote health and healing, and to boost my body's immune system by natural supplementation, energetic protocols, alternative therapies, and lifestyle modification.
8. I understand quantum biofeedback is designed to reduce stress and pain naturally and non-evasively by enhancing the flow of energy throughout the body. The biofeedback device is regulated by the Food and Drug Administration (FDA) and registered for stress and pain detection and reduction.
9. The Biofeedback device, nor the practitioner operates by diagnosing or prescribing. The Certified Biofeedback Specialist (CBS) I am attending is not an allopathic doctor (M.D.) and does not portray herself to be one. In addition Brooke Jensen does not diagnose, treat, or prescribe for my disease or conditions, nor perform any act that constitutes in the practice of medicine for which a license is required.
10. I understand the importance of communication with my physician and my responsibility to ask my medical doctor for permission to undergo biofeedback training if I wear a pacemaker or have any medical condition that may be exacerbated by relaxation.
11. Recommendations for other services/practitioners are only the advice of the practitioner I have consulted with and only to be followed if I believe it to be beneficial to my health and well-being.
12. I have solicited to this form of holistic healthcare and understand that Connection 2 Health’s services are not to substitute for standard medical, chiropractic, or psychotherapy treatment, nor veterinary care for my pet.
13. All information disclosed will be respected and kept confidential.
14. There will be a fee for returned checks.
15. A minimum fee of $20 or 20% of the set consult fee is charged for no-show appointments.
16. Connection 2 Health to does not deal directly with insurance companies but will provide an invoice. There are no refunds for the services provided.