Initial Client Intake Form - Distance Healing

Please take your time to carefully fill out this form with as much detail as possible related to your overall health. 

Contact Information
Full Name *
Full Name
Medical History
In order to help us meet your needs as a patient, we ask that you provide us with the following information. It is important that all information is reported accurately. If at any time there are changes in your condition, please notify your provider.
Please list all medications, supplements and herbs, including frequency of use and dosage.
Marital Status
What is your current occupation?
Please list your top three health concerns that you would like to address with Pure Balance.
Please list all known medication, food and environmental allergies.
Please describe in as much detail as possible your family medical history, including parents, siblings, grandparents and children.
Please list all hospitalizations, surgeries, procedures, transplants and injuries, including dates.
Current Conditions
Please check all conditions that you present with.
General Symptom Profile
Please check all that you have experienced within the past year.
Cardiovascular Symptom Profile
Please check all that you have experienced within the past year.
Respiratory Symptom Profile
Please check all that you have experienced in the past year.
Gastrointestinal Symptom Profile
Please check all that you have experienced within the past year.
Genitourinary Symptom Profile
Please check all that you have experienced in the past year.
Neuropsychological Symptom Profile
Please check all that you have experienced in the past year.
Musculoskeletal Symptom Profile
Please check all that you have experienced in the past year.
Please feel free to use this space to elaborate on symptoms or to add any additional symptoms that you may have experienced in the past year or may be currently experiencing.
Do you have any concerns related to menstruation, peri-menopause or menopause? Please describe the regularity of your cycle. Have you ever had an abnormal mammogram/thermography scan? Have you ever had abnormal lab findings? Have you had a hysterectomy or partial hysterectomy? Do you have a history of endometriosis?
Please tell us if you have any men's health concerns. Have you had a recent prostate exam, PSA test or colonoscopy? Do you have sexual dysfunction or impotence? Have you had a vasectomy?
Nutritional Intake
Please check all that apply.
Please use this space to express any concerns about nutrition you may have.
Do you consume alcohol? If yes, what? How much? And for how many years?
Do you smoke? What? And How much? Have you tried to quit? How many times?
How frequently do you have bowel movements? What is the typical color and consistency?
Please describe your current level of physical activity.
On a scale of 0-10 (0 being no stress and 10 being maximally stressed) please rate your emotional stress level.
Please describe your sleep patterns and average sleep per night. Do you wake feeling refreshed?
Please describe your 3 greatest physical health assets and 3 greatest areas of need.
Please describe your 3 greatest intellectual health assets and 3 greatest areas of need.
Please describe your 3 greatest emotional health assets and 3 greatest areas of need.
Please describe your 3 greatest spiritual health assets and 3 greatest areas of need.
Client Agreement
CLIENT AGREEMENT 1) AGREEMENT - This contract between Krystal Couture / Pure Balance Holistic Healing, LLC (hereafter “Krystal Couture”) and you, the “Client”, governs assignments executed by Krystal Couture for the Client for one year after agreement submission, and constitutes the entire agreement between the parties concerning those assignments.

 2) TERMS - This contract between Krystal Couture and the Client will remain in effect the duration of the Distance Healing Sessions that the Client has hired Krystal Couture for. 3) PAYMENT - Client will be charged at the start of each session. A credit card will be held on file as long as the client remains active. The client will be fully responsible for all bank fees for insufficient funds, closed accounts, expired cards, etc. In addition, you are responsible for all collection fees, legal fees, or other fees incurred by Krystal Couture associated with your negligence to pay per the outlined schedule. There will be absolutely NO REFUNDS provided, under any circumstances. Clients are liable for the full amount, regardless of participation, engagement in, or completion of the program.  Krystal Couture will respect your privacy and will not disclose or share your confidential payment information.  4) COPYRIGHT – All Services and Program materials and all website content are copyright by Krystal Couture. No reproduction (including print electronic and web use in English or any other language) of materials or content is permitted without specific written permission authorized by Krystal Couture. All rights are reserved. This copyright agreement will remain in effect for the full duration of this contract and for the unforeseeable future. 5) CANCELLATIONS, POSTPONEMENTS - In the event that the Client cancels or is absent from a scheduled session without providing 24 hours notice, the Client shall forfeit the session. No refund will be provided. 6) SCHEDULE - The outlined schedule provided via www.purebalancept.com of the services or programs is subject to change at any time. 

 7) TECHNICAL MATTERS - Krystal Couture is not responsible for matters related to technology including website crashes or malfunctions.  8) INDEPENDENT CONTRACTOR STATUS - Krystal Couture acknowledges that she is an independent contractor, and is responsible for paying the proper taxes and insurance as such.

 9) CONFIDENTIALITY - The client recognizes upon their engagement with Krystal Couture that Krystal Couture must entrust the client with certain trade secrets and confidential information. Each client will keep secret and retain strictest confidence, and shall not, without the prior written consent of Krystal Couture, for any reason, directly or indirectly, divulge to any third party or use for his or her own benefit or the benefit of others, such confidential, proprietary, business, client, and trade secrets of Krystal Couture. This confidentiality agreement will remain in effect for the full duration of this contract and for the unforeseeable future. And of course, the client's health, personal and professional information will be kept in the strictest confidence. All details related to client coaching sessions will remain private and kept confidential. 10) NON-DISCLOSURE -The client shall not disclose or permit the disclosure of any confidential information that they may receive in their participation in Krystal Couture's Services, Programs, Online Forums, Sessions etc. The client shall not use or permit the use of any confidential information detrimental to the Krystal Couture  including, but not limited to competing with Krystal Couture. The client shall use all confidential information that is presented for the benefit of Krystal Couture and members of Services, Programs, Online Forums, Sessions, etc. The client understands that Krystal Couture will not disclose private information without written permission to do so. The client understands that if they are participating in any internet based program and disclosing personal, business or any other information that they are doing so voluntarily and that this information may not be confidential due to the nature of the Internet. Krystal Couture assumes no responsibly. This non-disclosure agreement will remain in effect for the full duration of this contract and for the unforeseeable future.

 11) NON-COMPETITION - The shall not in any manner use materials and content from services, courses, programs, sessions, writings, etc to compete with Krystal Couture in any way, including but not limited to opening a company or program under the same or similar foundations to which Krystal Couture presents, solicit or call on, directly or indirectly, for the purposes of providing services, courses, programs, sessions, writings, etc, any clients/customers with whom Krystal Couture shall have dealt with at any time; directly or indirectly influence or attempt to influence an client or potential client of Krystal Couture to terminate or modify any written or oral agreement or course of dealing with Krystal Couture; influence or attempt to influence any person including but not limited to independent contractors, employees, affiliates and associates  to terminate or modify any written or oral agreement or course of dealing with Krystal Couture. 12) INDEMNIFICATION - To the fullest extent permitted by law, the client hereby indemnifies and holds harmless Krystal Couture / Pure Balance Holistic Healing, LLC, and each of their founders, officers, directors, members agents, subsidiaries, partners, employees, subcontractors and any other associates/affiliates from and against any and all liabilities, claims, damages, judgements, settlements, losses and expenses, including but not limited to attorney fees, arising out of injury or damage or damage to persons or property caused by any act or omission of Krystal Couture, including negligent acts of Krystal Couture /Pure Balance Holistic Healing, LLC or its' employees, arising out of any manner connected with the provision of the Services under this contract while engaged in services, programs or content provided and forever.  In the event that the client breaches the terms of this contract and Krystal Couture is forced to initiate litigation for such breach, attorney's fees will be awarded to the prevailing party.  Preceedings for any discrepancy will be handled in the following order: 1.  amicably  2. mediation 3.  legal. 13) NO GUARANTEES - The client understands that Krystal Couture cannot in anyway guarantee any results, outcomes, solutions or changes related to services, programs, content and materials provided. The client understands that their own health, beliefs, energy, commitment and a wide range of other factors contribute greatly to their own progress. While Krystal Couture intends to hold space for your healing and provide the highest quality energy, service, and recommendations possible, the client is responsible for their reception, integration and implementation of the healing session. I, THE CLIENT, ACKNOWLEDGE THAT I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND AND AGREE TO ALL OF THE PROVISIONS CONTAINED THEREIN, AND AGREE THAT THE TERMS CONTAINED IN THIS AGREEMENT ARE FAIR AND REASONABLE. BY TYPING MY NAME BELOW, I AGREE TO ENTER INTO THIS CONTRACT.
Please initial in agreement with the Client Agreement
Typing your full name below serves as your electronic signature and affirms that you have provided accurate information; understand and agree all Pure Balance Holistic Healing, LLC policies; and consent to treatment provided by providers at Pure Balance Holistic Healing, LLC.