New Client Registration

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Welcome to Allmond Wellness! We are a health coaching practice focused on assisting client’s in evaluating their diet, lifestyle, genetics, toxin exposure, levels of inflammation, gut health, and chemical imbalance. Removing impediments in these areas will always lead to improved brain health and longevity. Are you ready to make changes? Come join us on what will be an enlightening and exciting journey to wellness!

NEW CLIENT REGISTRATION FORM

***Allmond Wellness protects your privacy with a 100% guarantee! Your information will not be shared with ANYONE unless you endorse it by filing an official Release of Information Form with our office***

Today's Date*

How did you hear about us?*

What are your health goals?*

CLIENT INFORMATION

Name*

First Last

Date Of Birth*

Age*

Gender*

Full Home Address

Street Address Address Line 2 City State ZIP Code

Best Email Address*

Best Phone Number*

Occupation*

Employer*

CURRENT HEALTH CARE TEAM

Primary Care Physician Name, Address, and Contact Number:

Therapist Name, Address and Contact Number:

EMERGENCY CONTACT INFORMATION

Emergency Contact Name and Number:*

Relationship to contact:*

For enhanced communication purposes, I grant Allmond Wellness permission to text me or leave automated voicemail messages regarding appointments. (TYPE NAME)*

FEES & SERVICES

Allmond Wellness is a fee-for-service practice. We do not accept insurance but, are always happy to supply a “superbill” with coding that can be submitted to your insurance company for potential reimbursement.

90 Minute New Client Integrative Evaluation- This includes a 90 minute evaluation appointment, review of submitted pertinent past records, ordering of phase one lab testing and treatment planning. Gut/microbiome testing is most commonly part of initial recommendations as there is such a direct connection between the gut and brain!-$400

60 Minute Follow Up Appointments-$250

30 Minute Follow Up Appointments-$125

“Medication Focused Evaluation” Not everyone wants or needs a comprehensive integrative approach to their mental health. This service is for clients who prefer to focus on medication options. Initial evaluation is a 1 hour appointment ($250) and follow up medication management appointments are 30 minutes ($125)

“Focused Gut Work” It is now common knowledge that ALL disease starts in the gut! It is no longer true that “you are what you eat” but, more accurately “you are what you digest!” For that reason, Deanna has sought specialty training in the area of digestion, microbiome health and inflammatory bowel disease. This service is for anyone who would like to focus on gut testing, treatment protocols and lifestyle changes aimed at improving overall health and well-being. You needn’t be an established client. This service starts with a comprehensive digestive questionnaire that will be reviewed during an initial 30 minute appointment ($125) A Gut Zoomer Assay is then ordered from Vibrant Labs (cost of testing is independent of Deanna’s fees=$478) and a follow up appointment is scheduled to review the results and discuss treatment recommendations.

“Genomind Genetic Testing Only” This service is for clients who just want to have the Genomind Assay ordered and interpreted. A brief evaluation form will be submitted prior to Deanna ordering the assay kit. Once results are in, an appointment will be scheduled to review the results and any treatment recommendations ($125). You needn’t be an established client.

Services Interested In*

Initial New Client Evaluation

Medication Focused Evaluation

Genomind Genetic Testing Only

Please list a credit or debit card for us to keep on file. You will never be charged until services are rendered. The information will be entered into Square and then destroyed. Only the last 4 numbers are shown in Square. Thank you!

Name On Card

Card Number

Card Expiration

3 digit code on the back

OFFICE HOURS

By appointment only

LATE FEES AND CANCELLATIONS Once an appointment is scheduled, it is expected that you will keep the appointment and pay for it at the time of service. Should you need to cancel or reschedule said appointment, it is kindly requested that you do so at least 24 hours in advance. Violations of this cancellation policy will lead to a $50 fee.

THANK YOU!

Thank you for your interest in Allmond Wellness! We are excited to help you get started on your road to healing and wellness. By signing below, you attest that you have read the information and agree with stated policies. Your paperwork will be reviewed in the order in which it was received, and you will be contacted to schedule your intake appointment as soon as possible. In the meantime, direct any questions you may have to: Allmondwellness37@gmail.com.

Consent*

Checking this box acknowledges that you have reviewed the “Privacy Policy” at the bottom of website