New Patients

Please complete the form below before your first visit, or bring your completed printed forms with you to your appointment.

Printable Forms

  • Please note that when stress management techniques are implemented, blood pressure may begin to lower naturally. Monitoring of blood pressure by/communication with your medication-prescribing doctor is advised to prevent side effects of low blood pressure.

    The Client understands that the role of the Consultant is not to provide health care, medical, nutrition or therapy services; or to diagnose, treat, or cure any disease, condition, or other physical or mental ailment of the human body. Rather, the Consultant is a guide and educator who had been trained in stress management techniques to assist clients reach their own stress management goals by helping clients understand and implement STRESS MANAGEMENT TECHNIQUES. The Client understands that the Consultant is not acting in the capacity of a doctor, psychologist or other licensed or registered professional, and that any advice given by the Consultant is not meant to take place of advice by these professionals. If the Client is under the care of a health care professional or currently uses prescription medications, the Client should not discontinue any prescription medications without first consulting his or her doctor.

    The Client has chosen to work with the Consultant and understand that the information received should not be seen as medical or nursing advice and is not meant to take the place of seeing licensed health professionals.


    The Client acknowledges that the Client takes full responsibility for the Client’s life and well-being, as well as the lives and well-being of the Client’s family and children (where applicable), and all decisions made during and after this program.

    The Client releases the Consultant from any and all liability, damages, causes of action, allegations, suits, sums of money, claims and demands whatsoever, in law or equity, which the Client ever had, now has or will have in the future against the Consultant, arising from the Client’s past or future participation in, or otherwise with respect to, the Program, unless arising from the gross negligence of the Consultant.


    The Consultant will keep the Client’s information private and will not share the Client’s information to any third party unless compelled by the law.


    In the event that there ever arises a dispute between Consultant and Client with respect to the services provided pursuant to this agreement or otherwise pertaining to the relationship between the parties, the parties agree to submit to binding arbitration before the American Arbitration Association (Commercial Arbitration and Mediation Center to the Americas Mediation and Arbitration Rules). Any judgment on the aware rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof. Such arbitration shall be conducted by a single arbitrator. The sole remedy that can be awarded to the Client in the event that an award is granted in arbitration is refund of the Program Fee. Without limiting the generality of the foregoing, no award of consequential or other damages, unless specifically set forth herein, may be granted to the Client.

    This agreement shall be construed according to the laws of the State of Pennsylvania. In the event that any provision of this Agreement is deemed unenforceable, the remaining portions of the Agreement shall be severed and remain in full force.

    If the terms of this agreement are acceptable, please sign the acceptance below. By doing so, the Client acknowledges that: (1) he/she has received a copy of this letter agreement; (2) he/she has had an opportunity to discuss the contents with the Consultant and, if desired, to have it reviewed by an attorney; and (3) the Client understands, accepts and agrees to abide by the terms hereof.