215-340-3930

215-340-3930

Well of Life Center for Holistic Healthcare
Well of Life Center for Holistic Healthcare

NEW CLIENTS

Critical Care Application

Thank you for your interest in the Critical Care Program with the owner, founder, and Critical Care Clinician, Cynthia Hofmann-Coale. Below is an application that we need you to fill out in order to be approved for our Critical Care program.

Please take time to carefully review the program and consider the time and financial commitments and whether it is feasible for you and your family.

Once we have received the application back from you, we will be personally reviewing it with Cynthia and will determine whether or not you are approved for the Critical Care Program at the Well of Life Center.

PROGRAM COMMMITMENT

At the Well of Life Center, we are committed to doing everything in our power to restore health to your body as a whole. In turn, we require that all Critical Care clients commit wholeheartedly to the program that we offer, and to the nutritional protocol that your Clinician designs specifically for you. Please take the time to review the requirements shown below and consider whether they are feasible for you and your family.
Critical Care New Client Appointments are approximately 3 hours in length, with a charge of $635. This fee is required at the time of scheduling your appointment and is non-refundable.
The cost of nutrition at your Initial Consultation will be roughly $750-1,000. The nutritional cost at follow up visits cannot be accurately predicated as each case is bio individual; however, we recommend budgeting a minimum of $300 per visit.
Critical Clients are required to be seen bi-weekly for the first three visits. After this point, your Clinician will let you know if your body is in a place that you can come less frequently. Your first three visits are scheduled by the Client Advocate when you schedule your new client appointment. You have the right to cancel these appointments after your new client appointment and before your first follow-up appointment if you so desire.
The first six-follow up appointments are sold in a pre-payment package. The cost for this package is $750. This payment is due by the date of the first package visit and is non-refundable and non-transferrable.
Upon completion of first six follow up visits, you are now eligible to purchase your visits on a pay-as-you-go basis instead of purchasing a package.
You are required to keep a detailed food log each week that you will need to bring to each appointment
If you marked "unable" for any of the commitments above, but still believe you fall under the category of "Critical Care," please check the boxes below:
If you marked "unable" for any of the commitments above and you do NOT believe you fall under the category of "Critical Care," please contact our Client Advocate Team at newclient@welloflifecenter.com and let them know that you would like more information about scheduling with a Senior or Associate Clinician.

PERSONAL PROFILE

Address:
How did you hear about us?

HEALTH HISTORY

Have you received any diagnosis at this time?
Are you currently taking any medications?
Are you currently under a holistic practitioner's care?
Is your dentist a biological dentist?
Have you had an mercury fillings?
Should we find that your mercury fillings are negatively impacting your current state of health, would you be willing to have them removed?

DIETARY INTAKE: DAY 1

Your diet may be one of the keys to better health. We require a minimum of 3 days of food intake. You do not need to wait 3 days to fill it out; you can simply give us a detailed example of what your typical dietary intake is during this course of time. Be sure to include approximate amounts of meat, dairy, vegetables, fruits, breads, cereals, grains, fats (butter, margarine, oil, etc.), candies, sweets, junk food, and liquids, including water.
BREAKFAST:
LUNCH:
DINNER:
SNACKS:
WATER INTAKE:
HOURS OF SLEEP:
QUALITY OF SLEEP:
Please rate your quality of sleep (1=Poor, 5=Good)
BOWEL MOVEMENTS:

DIETARY INTAKE: DAY 2

BREAKFAST:
LUNCH:
DINNER:
SNACKS:
WATER INTAKE:
HOURS OF SLEEP:
QUALITY OF SLEEP:
Please rate your quality of sleep (1=Poor, 5=Good)
BOWEL MOVEMENTS:

DIETARY INTAKE: DAY 3

BREAKFAST:
LUNCH:
DINNER:
DINNER:
WATER INTAKE:
HOURS OF SLEEP:
QUALITY OF SLEEP:
Please rate your quality of sleep (1=Poor, 5=Good) (copy)
BOWEL MOVEMENTS:

Tell us more about you...

CLIENT CONSENT

Please click HERE to read our Agreement and Release of Liability. Then, sign by typing your full name in the box above. By signing, you are acknowledging that you have read and accept the terms and conditions of the Agreement and Release of Liability.