Homeopathy Intake | Held By Her

welcome to your next evolution

I'm so glad you're here and I look forward to working with you. Here's how it will go...

First, please complete the Intake Form below - this is my departure point for understanding where you are at in your health journey. During our initial consultation, we will go into depth of your chief complaint, overall state of health, personal history, strengths & challenges. I will send you the remedies I select for you & you can begin dosing them as directed. You will track any shifts you experience until our first follow up, 4 - 6 weeks after our initial consultation, at which point we will check in & continue to hone in on which remedies can continue to support you as you heal.

New Practitioner Pricing: $344 CAD
This includes our initial consultation as well as two follow ups, along with touch ins as needed along the way. This reflects a fair energy exchange & an investment in your long term health & vitality. This price does not include the cost of remedies which can vary from $20 - $80 + shipping, depending on your journey. Payment can be made via etransfer once booking is confirmed.

Are you looking for support for your little one? Click the button below.

Adult Homeopathic intake Form

Please complete all the questions below. Allow yourself the space to consider your answer to each question, but definitely don't overthink things either. Provide as much or as little information & context for each question as you feel comfortable - there are no right or wrong answers. We will discuss everything during our initial consultation.

First name

Last name

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Birthday

Year

Month

Day

Why are you seeking homeopathic support?

What is your primary complaint that you would like addressed?

When did this issue arise? What was happening in your life around that time? Do you have any sense of what could have caused / could be causing it?

What aggravates your primary complaint? ....this could be a time of day / year / cycle, a kind of food, weather, movement, light, noise, heat / cold, or anything else you can think of. Be specific.

Is there anything that improves or makes it better?

Is there any symptoms (could be physical, mental, emotional, etc) that accompany your primary complaint?

What are the greatest joys you have had in your life?

What are the greatest griefs you have gone through in your life? How did you respond?

When and in what situations do you feel frightened or anxious? Do you have any major fears (for example dark, being alone, crowds, heights, flying, failure, etc)?

What do you need to feel happy, content, and at peace?

What is most important for you? What things in life do you place a high value upon?

In what situations / circumstances do you really struggle? What happens for you?

When you are upset, do you tend to tell a lot of people, or keep it close to your chest?

Do you cry easily? In what situations?

How is your sense of self-confidence and/or self-worth?

How would someone close to your describe you? The good and the bad?

Do you tend to be neater and more fastidious than others? Or are you more relaxed / casual?

How do you feel about time? Are you able to be present? Do you feel hurried? Does it feel like there is never enough time?

What is your digestion like these days? Are you experiencing any acute or chronic digestive issues? Please explain

How do you feel before, during, and after meals? How do you feel if you go without a meal?

What foods do you love? What foods are you adverse to? What foods do you react poorly to?

How is your sleep currently? Do you have trouble falling asleep? Do you often wake up in the night at a particular time? What makes you restless, or sleepy?

How do you feel in the morning? Do you feel like on a day to day basis you are able to recover from the energy you expend?

Do you prefer to sleep in a particular position?

Do you have any recurring dreams?

Please mention any kinds of weather that affect you, and how they affect you.

Do you have any special reactions before, after, or during a storm?

How do you react to drafts of air? For example, an open window or having a fan on you? Do you like to sleep with the window open, even when it's cold outside?

What about warmth in general? For example a warm room, or the warmth of the bed or a heater, etc.

Are you generally a warm or cool person - temperature wise?

Do you tend to perspire a great deal? If so, when? And where on the body (feet, head, hair, armpits, face)?

When do you have the most energy during the day? When tends to be your down / tired time of day?

If you are a menstruating woman, how is your cycle overall? Do you track your cycle? What is the quality of your moonblood? Do you monitor your fertility signs such a cervical mucus?

Do you experience hormone-related symptoms such as acne, bloating, painful periods, PMS, irregular hair growth, etc?

How many pregnancies have you had? How many children do you have?

At what age did you have your menarche (your first period)? If you have moved through menopause - at what age?

Do you frequently get colds and flus? How does your system recover?

Do you have any history of recurring issues such as tonsillitis, strep, mono, coldsores, etc?

Have you had Covid? Did you have any lingering or troubling symptoms form after having Covid?

Do you currently have or have a history of: warts, tumours, cysts, polyps?

Do you have notable discharges?

Do you have any medical diagnoses? How are you treating any medical issues you are experiencing?

Current Medications and / or Supplements (if any)

Is there anything else you feel I should know about you right now?

By checking this box and signing below, you agree that you have read, understood and agree to the terms outlined in the Student Case Study Consent Form. IT IS IMPORTANT THAT YOU TAKE THE TIME TO FULLY READ THROUGH THIS.

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held by her
herbs & homeopathy

welcome to your next evolution

Are you looking for support for your little one? Click the button below.

Adult Homeopathic intake Form

BE HELD BY HER

HELP

NAVIGATE

CONTACT

beheldbyher@gmail.com
@held.by.her

welcome to your next evolution

Are you looking for support for your little one? Click the button below.

Adult Homeopathic intake Form

BE HELD BY HER

HELP

NAVIGATE

CONTACT

beheldbyher@gmail.com @held.by.her

beheldbyher@gmail.com
@held.by.her