SEATTLE: 9730 3rd Avenue NE, suite 202, Seattle, WA (parking lot on 4th Avenue)
KIRKLAND: 13615 100th Ave NE, Kirkland, WA 98034
Forms, Assessment Tools & Food Journals
Online Resources, Recipes and Health Articles
Whole Body Wellness Support
21 Day Detox Questionnaire for Group Program
Group Detox Questionnaire for 21-Day Detox
Step 1 of 3
District of Columbia
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
List any known allergies? (Include foods)
Do you a have dairy allergy?
How many ounces of water do you drink per day?
Less than half my body weight in ounces.
Half my body weight in ounces.
More than half my body weight in ounces.
How many sodas &/or coffees do you drink per week?
More than 10
How many alcoholic beverages do you drink per week?
More than 10
How many hours of exercise do you do per week?
More than 15
Do you sleep well?
Do you wake up during the night?
If so, what time?
How many bowel movements do you have per day?
More than 2
What is the consistency of your bowel movements?
Loose to Normal
Normal to Constipated
Choose areas where you experience pain.
Do you crave salt?
Do you crave carbs?
Do you crave sugar?
Would you like your weight to change?
What is your goal for the 21-Day Detox Purification Program?
Increased Athletic Ability
Healthy Eating Lifestyle
How did you hear about the 21-Day Detox?
Health Care Practitioner Referral
Pick Your Group Detox Start Date
SPRING ~ 3/19, 3/26, 4/2, 4/9
SUMMER ~ 6/11, 6/18, 6/25, 7/2
FALL ~ 9/17, 9/24, 10/1, 10/8
NUTRITIONAL THERAPY INFORMED CONSENT AND DISCLAIMER for Nourish and Revive, LLC: Heidi Jo Rickard, Nutritional Therapy Consultant and Reiki Master
Before you choose to use the services of a Nutritional Therapy Consultant, please read the following information FULLY AND CAREFULLY. Nourish and Revive, LLC 9730 3rd AVE NE, Suite 202 Seattle, WA 98115 (425) 686-8776 www.nourishandrevive.com GOAL: Our goal is to encourage people to become knowledgeable about and responsible for their own health, and to bring it to a personal optimum level. Nutritional therapy is designed to improve your health, but is not designed to treat any specific disease or medical condition. Reaching the goal of optimum health, absent other non-nutritional complicating factors, requires a sincere commitment from you, possible lifestyle changes, and a positive attitude. As a Nutritional Therapy Consultant, I am trained to evaluate your nutritional needs and make recommendations of dietary changes and suggest nutritional supplements. As a Reiki Master, I am trained to promote relaxation, lower stress levels, help to relieve the symptoms of pain and promote the overall healing process. As a Reiki Master and Nutritional Therapy Consultant, I am not trained to provide medical diagnoses, and no comment or recommendation should be construed as being a medical diagnosis. HEALTH CONCERNS: If you suffer from a medical or pathological condition, you need to consult with an appropriate healthcare provider. Nourish and Revive, LLC is not a substitute for your family physician or other appropriate healthcare provider nor is licensed to diagnose or treat pathological conditions, illnesses, injuries, or diseases. We offer no treatment or cure of conditions or disease. Nutritional therapy may be a beneficial adjunct to more traditional care, and it may alter your need for medication, so it is important you always keep your physician informed of changes in your nutritional program. If you are using medications of any kind, you are required to alert Nourish and Revive, LLC to such use, as well as to discuss any potential interactions between medications and nutritional products with your doctor/pharmacist. You agree to discuss all supplementation protocol recommendations with your doctor before usage. If you have any physical or emotional reaction to nutritional therapy, discontinue their use immediately, and contact your doctor and Nourish and Revive, LLC to ascertain if the reaction is adverse or an indication of the natural course of the body's adjustment to the therapy. I certify that I am not pregnant and if I become pregnant will notify my doctor and Nourish and Revive, LLC immediately to review the recommended protocols. I certify that I am 18 years old or older. COMMUNICATION: Every client is an individual, and it is not possible to determine in advance how your system will react to the supplements. It is sometimes necessary to adjust your program for maximum progress of your nutrition healing. It is your responsibility to do your part by using your nutrition guidelines, exercise your body and mind sufficiently for a positive balance, eat a proper diet, get plenty of rest, and learn about nutrition. You must stay in contact with the Nourish and Revive, LLC so we can let you know what is happening and the best course of action. You should request your other healthcare provider, if any, to feel free to contact Nourish and Revive, LLC for answers to any questions they may have regarding nutritional therapy. LICENSURE: Heidi Jo Rickard, NTC- Nutritional Therapy Consultant and Reiki Master is not licensed or certified by any state. A Nutritional Therapy Consultant ™ is trained by the internationally recognized Nutritional Therapy Association, Inc.® A Reiki Master- is trained through level III, Master in the Reiki Healing Arts. Heidi Jo Rickard is an ordained Christian minister. Program Guidelines and Agreement 1. Always consult with your health care professional to see if you are healthy enough for detox. Always consult your doctor about and new or modified nutritional and exercise program you introduce into your life. You agree that you will consult with your doctor. 2. Please keep in mind that our nutritional products DO NOT cause “side effects” as they are not drugs. Occasionally after starting a nutritional program, you may feel a temporary worsening or even feel “sick.” If this occurs, call, text or email the office. Sometimes these “flare-ups” are actually a “Healing Crisis” which indicates your body is starting to heal by throwing off toxins that have been keeping you sick. By fine-tuning your program, we can help you get through these types of situations much more smoothly, if they even occur. When you are not doing well is when it is often most important to contact us so we can fine-tune your program and help you correct the underlying cause of the problem of the symptoms more rapidly. 3. Please consider all the dynamics in your life that could interfere with or prevent you from doing or completing your health repair program. For this period of time, please put your health first so body can repair the years of damage…and then make it a lifestyle change. Your body will thank you! By typing in your name, you are agreeing as a signature to confirm that you have read and fully understand the above disclaimer and the program agreement, and are in complete agreement thereto and do freely and without duress sign hold harmless and consent to all terms contained herein.