Naturally Unbridled - Life & Wellness Coaching

NU Client Intake Application

To qualify to receive a FREE 30-minute consultation, please complete the form below. Once you submit the form, you will receive an email with more information. There is no obligation to enroll in a coaching program. Your information will be kept in complete confidence and will never be shared with a third party.

An initial consultation involves a phone conversation where you and Patti Bartsch, M.A., Ph.D. will discuss your current situation, challenges and goals. You will work together to schedule the call at a mutually convenient time and you will have the opportunity to ask questions in addition to the coaching information you will receive based on your NU Client Intake Application.

There is no risk and no obligation — just the opportunity to take the next step toward your Naturally Unbridled life!

Patti will have received and reviewed your information prior to the call so that she can prepare to discuss your particular concerns. She will also provide information about the various coaching programs so that you can determine which option is best for you.

Name: (first, last, prefer to be called) Please enter your name

Address:

City

State/Province:

Zip Code:

Country:

Phone:

Email: Please enter your emailInvalid email format

Date of birth:

Occupation:

Number of adults in household:

Number of children in household:

Blood type: (if known)

Eye color:

Primary health concerns:

Health history: List significant current or prior health matters including, but not limited to,
allergies, serious injuries, hospitalizations, surgeries, diseases, etc.

Medications and Supplements: please list all medications, remedies, and supplements
you are taking and include the dose, duration and reason for taking them.

List any additional health services you are receiving including, but not limited to chiropractic
care, massage, acupuncture, physical therapy, nutritional counseling, etc.

Describe the physical activities you participate in:

Describe the social activities you participate in:

List your reasons for investigating Naturally Unbridled Holistic Life & Wellness Coaching;
what goals would you like to achieve?

How did you hear about Naturally Unbridled?

Please confirm you agree Agree: Patti Bartsch, Ph.D., of Naturally Unbridled, is an alternative and complimentary holistic health practitioner. She is not a licensed physician or medical doctor, therefore, does not treat, diagnose or cure diseases.

After clicking the "submit" button below, you will receive an email with information on scheduling your FREE initial consultation. Please be sure to check your spam folder if you do not see the email in your inbox.