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Name

Age

City and State

Please tell me about your current health struggles

How would your life change if you were able to overcome these challenges?

Have you ever worked with an integrative/functional health practitioner before? What was your experience like?

I understand that this work is not eligible for insurance coverage, but that I may use HSA/FSA funds to pay for clinical services only (not supplements) per my individual insurance plan. Some supplements and lab work MAY be covered by insurance, and Sarah can sign off on those if applicable.

I understand that Sarah Diamond is not a medical provider and our work together does not constitute medical care. I understand that Sarah cannot provide CPT or diagnostic codes in relation to our work.

Anything else you'd like to add?

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