Fertile Ground Wellness Center

A place to grow...Our mission is to provide compassionate integrated health care to women and families with emphasis on caring for the whole person, in a nurturing environment that promotes wellness for our patients, staff, and community.

Patient Forms

Are you a new patient? Please print and fill out the appropriate forms below. Thank you!

General Forms

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Name		Description
	HIPAA Form and Protecting Your Health Information	This form details how medical information about you may be used and disclosed and how you can get access to the information. Please read this before you come in for your first appointment. Do not print out and bring with you.
	New Patient Intake Form	This is a required form for anyone who has not been into Fertile Ground for acupuncture, nutrition therapy, or massage therapy. Please print and fill this out before your first appointment.

Acupuncture

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Name		Description
	Acupuncture Disclosure Form	This form is for all acupuncture patients. Please read before you come in for your first appointment. Do not print and bring in with you.
	Acupuncture Informed Consent	This form is for all acupuncture patients. Please print, fill out and bring this with you to your first acupuncture appointment.

Hypnotherapy Forms

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Name		Description
	Client Disclosure Statement	Please print off, read, sign this paperwork, and bring it with you to your hypnotherapy session
	Hypnotherapy for Fertility Questionnaire for Women	Please print off, read, sign this paperwork, and bring it with you to your hypnotherapy session

Nutrition Forms

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Name		Description
	Welcome Letter and Important Information	This form is for all Nutritional Consult patients and contains important information for your first appointment.
	Nutrition Intake-Fertility	This form is for Nutrition appointments with a focus on fertility.
	Nutrition Intake-General	This form is for general Nutritional appointments.

Psychotherapy Forms

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Name		Description
	Notice of Privacy Practices	Required form for patients seeing Leslie McCleary, LCSW
	Client Information Form	Required form for patients seeing Leslie McCleary, LCSW
	Therapist-Client Contract	Required form for patients seeing Leslie McCleary, LCSW

Document Library

Name		Description
	Maya Abdominal Massage Intake Form	This form is for all Maya Abdominal Massage patients.
	Massage Intake Form-General	This form is for general massage appointments.
	Yoga Waiver	Yoga Waiver
	Acupuncture-General Health Intake Form	This form is for patients coming in for acupuncture to treat general health concerns.
	Acupuncture-Female Fertility Intake Form	This form is for women patients coming in for acupuncture to enhance fertility.
	Lactation Support Intake Form	This form is for patients coming in for lactation support.