• Application and Health History

  • We will never share your email or phone number. They are used only for communication between the client and Integrative Health Coaching Services.

  • Diet and Exercise

  • Present Complaints

  • Medical History

  • This section is for Women Only

  • If you are not having regular menstrual cycles, please answer the questions below according to when you DID have menstrual cycles.

  • Legal Documentation

    The following forms are MANDATORY. We cannot legally see you if these are not read and signed in full. Failure to sign these notifications before submitting this document will result in automatic rejection of your appointment request. We apologize for any inconvenience.

  • Integrative Health Coaching Services is a group of Certified Health Coaches who are also specialists in Autoimmune Disease, Neurological Disorders, CIRS, and related disorders such as environmental and toxin based illnesses, thyroid disease, endocrine disorders, digestive, nervous system and immune related disorders. (See Staff for a list of disorders with which we assist). Our scope of practice is nutritional and lifestyle change. In 2017, Certified Health Coaches were recognized by Congress as an integral part of the future of healthcare in the United States of America. We are trained to address both objective and subjective measurements of health and to use our scope of practice to help people improve their health through nutrition and lifestyle changes.


    We are not medical doctors. This means that no information from any of our staff or providers is meant to diagnose, treat, or cure any disease and is not considered to be a substitute for any medical treatment. Any information shared during our consults or programs is meant to be for educational purposes only. While the statements, education, methods and materials used for in our health clinic are based upon science, research and clinical experience, they have not been evaluated or approved by the FDA.


    We are not covered by HIPPA. However, every effort will be made to keep your personal information private. Our email is HIPPA compliant. At no time will we be sharing your health or medical information without your permission. Please make sure that you protect any sensitive material by only discussing it in our office or over one of our secure email addresses.


    By signing this form, you are stating that you have been made aware of the above information.

  • I acknowledge that my first appointment(s) with Rebecca N Mills-Anderson, LLC, Integrative Health Coaching Services and current interactions with the staff do not imply a client-coach relationship between myself and any provider at Integrative Health Coaching Services or any of the related companies. I acknowledge that this is a consultation for application into acceptance into the practice. Any information provided during these appointments are not intended as medical advice and the practice or any of its employees or employers are not responsible for any decisions I make for my own healthcare as a result of the exchange of information or consultation. If I am accepted into care, then I will have a client-coach relationship with the provider(s).

  • You have requested services, or more information about the services available, from Integrative Health Coaching Services, A Rebecca N Mills-Anderson, LLC. Information may be provided to you in group or individual appointments. Because such information may involve confidential health information and proprietary business information, we do not allow any video or audio recording. Accordingly, you agree not to record, by any manner whatsoever, any IHCS provider or staff member, any other client or potential client of IHCS, or IHCS facilities or seminars. You agree that any recordings made in violation of this agreement shall become the sole and exclusive property of IHCS and shall not be used or disseminated to anyone outside of IHCS.


    You also agree that damages from a breach of this Agreement would be costly to prove. Accordingly, you agree to pay, upon demand, liquidated damages in the amount of $50,000 per violation for breach of any provision of this Agreement. You expressly agree that the liquidated damages outlined in this Agreement are reasonable estimates of the losses RMA and its providers would incur as a result of your breach. You agree to pay reasonable attorneys’ fees, expert witness fees, costs of investigation and proof of facts, court costs, and other litigation or collection expenses incurred by IHCS or its providers to enforce the terms of this Agreement.

  • Consult Office Policies


    Hello and Welcome! We are very excited to get to know you during your upcoming consult. Integrative Health Coaching Services is a new and comprehensive model of healthcare developed by those who have dealt with chronic conditions for those dealing with chronic conditions. Because of our experience with chronic conditions personally and professionally, we have a very high success rate of helping our clients meet their health goals (90%!).


    But before we get to know what makes you different from everyone else, we need to make sure we get to keep helping people get well by providing an environment that allows us to continue to give our very best!. One of those ways is to keep our waiting times down and to maximize the time we have with each client or applicant. Here is how you can help!

    1. Please be on time. Please make sure to be on time for all appointments so that we can avoid rushing our time with you. We need time to do our job and give the best service we can- the service that you deserve. Lateness may lead to a rescheduling of your appointment at the coach’s discretion and may be treated as a no-show. Your appointment time is reserved especially for you and are ready to give you the most value out of our time together!

    2. Missed Appointments and Re-Scheduling. In order to give you the time and respect you deserve, we limit how many appointments we have each week to make sure every client and applicant gets the time to be heard and get the answers and solutions they need to reach their goals. Because our amount of appointments are very limited, we ask that if you need to reschedule for any reason to please do so by the morning of the prior business day BEFORE your appointment so that we have time to fill that spot with someone that needs it. Failure to give proper notice may lead to charges for that time slot. We appreciate your help in making sure that we are able to help people like you and to continue giving the level of service that you deserve.

    Thank you for helping us make sure we can help those who need it!


    Sincerely,

    Rebecca Mills-Anderson, CHHC, BA, BS and the IHCS staff.

    Clinical Director of IHCS

  • By hitting 'SUBMIT' below you agree that your typed name is a legal signature agreeing to all legal documents above You are alleging that all information above is true to the best of your knowledge.

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