This is a strictly confidential patient medical record. It will be used to evaluate whether BeYOUtiful Minds & Fitness is appropriate for your health. None of the people you identify on this form will be contacted unless you provide express permission for BeYOUtiful Minds & Fitness to contact them.
*Please understand that our agency may not be able to meet your individual needs. For this reason, after the initial phone consultation or the in-home intake is complete we may refer you to an agency that is better able to suit your individual needs.