Client Consent & Disclosure Statement: I understand that herbalists are not licensed to practice medicine and do not diagnose, treat or prevent disease.
By signing below I acknowledge that I understand and consent completely to everything addressed in the Client Consent & Disclosure statement.
Intake For m:
The intake form is designed for you to gain clarity around your personal strengths and weaknesses and to identify the physical, emotional and spiritual patterns in your life that are contributing to and/or hindering your overall wellness. You are welcome to share as much or as little as you feel comfortable sharing. This process helps me get to know you and more importantly helps you to take a holistic look at yourself and your lifestyle.
A person's constitution is said to be determined at birth and is influenced by their genetics, environment, and lifestyle choices. Knowing your constitution can help you to understand your body's natural tendencies and make choices that promote health and well-being. The following questions will help us to identify your constitution so that we can create an individualized and energetically specific herbal protocol for you.
How would you describe your personality and/or your best and worst personality traits?
Select the foods that you eat the most.
Are you taking any prescriptions, herbs or supplements? If so, list them here.
How much water do you drink daily & what other liquids do you consume thoughout the day?
What kinds of healthy fats do you consume and do you consume them daily?
Do you exercise regularly?
Are you getting 7 - 9 hours of sleep nightly?
How are your energy levels?
Do you feel safe, secure & comfortable in your home?
Do you feel at home in your body?
Do you spend time in & feel a connection to nature?
Do you feel safe & secure in your relationships? And what are some of the roles you play in relationships?
Is there any family or personal health history that could be important for me to know?
Are you pregnant or trying to conceive?
What do you do for work & how do you feel about your work?
How many hours per week do you work? Do you feel you have a healthy work/life balance?
How do you feel on a day to day basis?
Are you able to identify, name & regulate emotions as they arise?
Do you have stress management practices?
Do you feel you have healthy communication skills?
Emotions are directly correlated with beliefs. Are you aware of any beliefs that are no longer serving you which may need to be examined or challenged?
Do you feel like you can trust yourself & your intuition?
What are some of your core values?
Do you feel like your thoughts & actions are in alignment with your core values?
Do you feel a sense of meaning & purpose in your life? Do you feel a connection to something greater than yourself?
What are some of your interests, inspirations, creative outlets, and/or hobbies?
What is your main health goal or concern & what do you hope to achieve from this consultation?
If you are experiencing symptoms, describe the nature of your condition & when symtoms arose.
How would you classify the frequency of your condition: constant, frequent, occasional, rare? How many times per week or month do symptoms arise?
How would you rate the severity of your symptoms on a scale of 1 - 5? Does this number fluctuate or is it consistent?
Have you noticed anything that makes the symptom/condition better or worse? Is there anything you can think of that you need to stop doing in order for your condition to improve?
If there was a trauma, accident, surgery, please describe briefly.
Do you have any allergies? If so please list them here:
Do you have any chronic skin conditions such as psoriasis or eczema?
Do you get sick frequently? If so, please explain:
Select any of the following conditions that you have experenced:
Please add anything else that feels important to share.
Payment for Consultation is $75 Submit
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