Suzi Cook

Certified BodyTalk Practitioner

Helping you heal

Hi, I’m Suzi. I’m excited that we get to work together to create the next step in your journey to living the life you want to be living.

Information and Consent Form

First Name *

Last Name *

Primary Phone Number *

Secondary Phone Number

Email Address *

Street Address *

Apartment, suite, etc

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Date of Birth

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Referred ByNot referredOther

Other:

Describe the problem(s) for which you seek help. Please include dates when each problem occurred:

What daily activities are you finding difficult or are limited because of your above complaints?

What are your goals from BodyTalk?

Please list any other kind of healthcare professional you are seeing for this/these problem(s):

My family stress is:NoneMinimalModerateSevere

My relationship stress is:NoneMinimalModerateSevere

My work stress is:NoneMinimalModerateSevere

My financial stress is:NoneMinimalModerateSevere

My health stress is:NoneMinimalModerateSevere

Do you have chronic or acute pain/discomfort in your body?YesNo

Please describe location, type of pain, and rate the pain from 1-10 with 1 being barely there and 10 being unbearable. List all areas of concern.

Is there anything else you would like to share?

Consent

I, {name-1-first-name} {name-1-last-name}, understand that the BodyTalk session(s) provided by Suzi Cook, Certified BodyTalk Practitioner is intended to enhance relaxation, increase communication within the areas of the body, and to educate me to possible energetic or emotional blocks that may create pain and disease. BodyTalk is non-invasive, safe, and objective. It utilizes the body’s own innate intelligence to reestablish communication within itself. I understand that BodyTalk is not a substitute for medical treatment or medications. I am aware that the BodyTalk Practitioner does not diagnose illness or disease nor does the Practitioner prescribe medications.

Signature *

Submission Date

09/27/2025

Suzi Cook

Information and Consent Form

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