Please answer all relevant questions as best as possible. Please submit this form prior to your New Client Intake Session.  Other forms and information may be emailed to you separately if needed.

All information will be kept confidential.

For children and teens, this form must be filled out by the parent or guardian aged 18 or older.

New Client Form

I hereby agree to the following: 1. DISCLAIMER: That the information I receive is for educational purposes only and should not be considered medical advice. That this information is provided to help me make informed decisions about my health; it is not meant to replace the advice of my primary care physician. That choosing a holistic approach through Nutrition Therapy means choosing personal responsibility for my health care. I understand that Sara Peternell is not liable or responsible for any harm, damage or illness arising from the use of the information contained herein.2. That I am participating in a Nutrition Therapy Program and/or Workshop, offered by Sara Peternell in Colorado, during which I will receive information and instruction about nutrition.3. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the Nutritional Therapy Program and/or Workshop.4. In consideration of being permitted to participate in the Nutritional Therapy Program and/or Workshop, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in the program.5. In further consideration of being permitted to participate in the Nutritional Therapy Program and/or Workshop, I knowingly, voluntarily and expressly waive any claim I may have against Sara Peternell for any injury or damages that I may sustain as a result of participating in the program.6. I, my heirs or legal representatives, forever release, waive, discharge and covenant negligence or other acts.7. I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above.8. I understand that payment is due in full at time of consultation.

Unused Content: