New Client Form

Please take a few moments to fill out our New Client Form.

Your privacy is important to us, and as with any communication with Barbra, your information will be kept strictly confidential.

Name *
Name
Date *
Date
Address *
Address
Phone (Home)
Phone (Home)
Phone (Cell)
Phone (Cell)
Date of Birth *
Date of Birth
(1-10: 10 = supportive, open communication / 1 = combative, difficult)
Release Form
I understand that Barbra White, Express Joy LLC, and Accepted As I Am does not diagnose or treat diseases.
I wish to state that I know that the practitioner is not a Medical Doctor, Doctor of Orthopedics or Doctor of Chiropractic or a Psychologist. Further, I know that the practitioner does not, nor will not attempt to treat, prevent, cure or relieve a human disease, ailment, defect, complaint, or other condition, whether physical or mental, by attendance or device, diagnostic test, or other means, or to offer, to undertake, attempt to do, or hold oneself out as able to-do any of these acts. Further, I know, the practitioner has training and experience in natural healing. As such, the sole function of the practitioner is to educate through lectures, tutoring, private consultations and conferences as to the historical uses of foods, vitamins, minerals, herbs, and homeopathic philosophy and remedies. I acknowledge that I have read, understand and agree with all of the above statements by my signature. I have been told, read and understand that the practitioner does not practice the application of scientific principles to prevent, diagnose or treat physical and mental disease, disorders or conditions.
I wish to state that the objective of the consultation on my part is for the purpose of education in Natural Health Sciences and is not to be construed as treating disease, but solely for the purpose of my education in the various disciplines in the Natural Health Sciences and a program for building my health up in accordance with Natural Law as explained to me by the practitioner. All professional fees are for information and educational consultations and not for Auricular Sessions or any other services.
I wish to state that in my conversation with the practitioner, I have been told that Homeopathic remedies are a part of the Materica Medica and that licensed physicians claim that it will have a certain effect. The practitioner has recommended to me that I consult a licensed physician as to the use of the material. I have asked that I may have the remedies recommended since it is a non¬prescription item. I acknowledge that I have read the above and understand and agree with the statements herein by my signature.
I have read and agree to these conditions, and verify this digital signature to be legally binding. *
Date of Agreement *
Date of Agreement
Payment Policy
Our experience has shown that it is wise to have an understanding with our clients as to our office policies and fees.
All clients are responsible to pay for each visit, unless other arrangements have been made in advance. We do not bill insurance. We accept cash, checks and credit card payments. All clients are responsible for full payment for services.
Agreement: My signature below signifies my agreement for payment in full. I understand I will be charged for a full session (just the minimum time: 1.5 hr) $150, if I do not give 24 hour notice.
I have read and agree to these conditions, and verify this digital signature to be legally binding. *
Date of Agreement *
Date of Agreement