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Botanic Illustrator

Herbal Consultation
Intake Form

Intake Form for Herbal Consultation with Justine

Once this form is submitted I will be in touch to schedule a one on one consultation where we will meet via Zoom for one hour. I will develop your herbal protocol based on the information gathered in this form and during our call.

Client Consent & Disclosure Statement:

I understand that herbalists are not licensed to practice medicine and do not diagnose, treat or prevent disease.

I understand that the services offered by any herbalist affiliated with Healer's Harvest are strictly informative and are intended to educate me on a variety of wellness practices, provide resources and empower me to be my own self care advocate.

I understand that Healer's Harvest and any of its affiliated herbalists are in no way offering medical advice and that consulting with my doctor before taking herbs is always recommended. If I should choose not to follow recommendations of my medical doctor, I understand that I am solely responsible for such decisions and will not hold any other persons responsible for any potential consequences of such decisions.

I recognize that adverse effects and allergies can occur after the use of any active substance including herbs, supplements, homeopathy and other natural modalities.

I will fully disclose any medications, over the counter drugs, herbs and supplements that I am taking or have taken.

I will discontinue use of herbs and inform my herbalist if I believe I am pregnant.

I will inform herbalists of all aspects of my health and any changes that occur. If I experience any adverse effects from herbs, I will discontinue use and inform the herbalist immediately.

I understand that herbal consultations are strictly confidential and that all of my personal information will be kept completely anonymous. 

I understand that my case details will be shared with a mentor and other herbalists as part of The Herbalist's Collaborative recorded Zoom Sessions for the purpose of the professional development, training and meeting certificate of completion requirements of Healer's Harvest's herbalists.

By signing below I acknowledge that I understand and consent completely to everything addressed in the Client Consent & Disclosure statement.

Intake Form:

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.

Select the foods that you eat the most.

Select any of the following conditions that you have experenced:

Thanks for submitting! We will be in touch with you shortly.

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