Come work with me

First name

Last name

Email

Phone

Address

Birthday

Month

Day

Year

What are your top 1–3 health concerns right now?

How long have you been experiencing these issues?

Have you worked with a Functional Medicine Practitioner in the last 3 years? If so what did you focus on?

Did you have any Functional Labs done, if so please list labs (not results) like OAT, Dutch

List any diagnoses you have received (if any):

Current medications (if any):

Current supplements (if any):

Which best describes what you are looking for right now?

One-time consultation

Short-term focused support

Ongoing integrative care

I’m not sure yet

Are you open to: (check all that apply)

On a scale of 1–10, how ready do you feel to engage in your healing process?

My services are private pay and range from $175–$1,800+. Are you prepared to invest in your care at this level?

Yes

No

Possibly depending on recommendations

Will you require a Superbill for your insurance?

Yes

No

I'm not sure

Are you currently in a medical crisis or needing immediate medical care?

Yes

No

Do you have any of the following?

What would feeling “better” look like for you 6 months from now?

Is there anything else you would like me to know before I review your application?

By submitting this form, I understand that: • This form does not guarantee an immediate slot into care • If accepted, I will receive a payment and scheduling link • Insurance is not directly billed • Labs and supplements are separate from program fees

Agree

Don't Agree

Important Notice The services, recommendations, and educational materials provided by Nurturing Remedies are intended for educational and informational purposes only and are not intended to diagnose, treat, cure, or prevent an disease or medical condition

I have read and understand the above notice.

Any nutritional, herbal, or dietary supplement recommendations are offered to support general wellness and have not necessarily been evaluated by the Food and Drug Administration. Individual results vary, and no specific outcomes are guaranteed.

I have read and understand the above notice.

Clients are encouraged to consult with their primary care provider or other qualified healthcare professional before making changes to diet, supplements, medications, or lifestyle, especially if pregnant, nursing, or managing a medical condition.

I have read and understand the above notice.

By submitting this form, you acknowledge that you are voluntarily participating and accept responsibility for your health decisions.

I have read and understand the above notice.

Christine Kane RD, LDN
Functional Nutrition
Herbal Therapy
Natural Plant Based Products

at the Natural Path Farm

Come work with me