Wellness Consults Intake Form

Name(Required)

First Last

Email(Required)

City

Country

Birthday

Whatsapp Number

Health Concerns (one per line)(Required)

What are your health goals?(Required)

Medications or nutritional supplements you are currently taking(Required)

Liability Waiver

RELEASE OF LIABILITY FOR PERSONAL OR ONLINE NUTRITION SESSIONS WITH ERICA BREEN

Wellness Consults with Erica Breen is not a replacement for Medical, Psychological or Psychiatric care.

Erica Breen offers Nutritional and Wellness Coaching to help you find a healthy balance in your life. However, you are responsible for your health and must determine whether Erica Breen is the correct person for you and your needs. If at any time you are unhappy with the results of your session(s), you should discuss this with Erica Breen and/or seek alternative Counseling.

By submitting this form, you are agreeing to release Erica Breen from any liability, legal or otherwise, for the outcome of the coaching sessions, or decisions you make as a result of them. Only if you are willing to take full responsibility for yourself and your own decisions, should you accept coaching sessions from Erica Breen.

No refunds will be given.

Date of Submission(Required)

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