homeopathy intake

potenized medicines that align your vital energy.

Thank you for taking the time to fill out this intake form. These are a series of questions to begin the process of me seeking to understand who you are, how you are, and how we can work together with homeopathy to support your healing journey. 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. I will review your answers and then we will discuss more during our initial consultation.

First name

Last name

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Birthday

Month

Day

Year

Why are you seeking homeopathic support?

What is your primary physical complaint? What doesn’t feel right in your body?

What is your dominant emotional state currently? What emotions are you experiencing the most on an ongoing basis? What challenges do you have here?

What is your primary physical complaint? What doesn’t feel right in your body?

What is your dominant emotional state currently? What emotions are you experiencing the most on an ongoing basis? What challenges do you have here?

Where are you on your spiritual journey? Whatever this question may mean to you…

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

If you are a menstruating woman, how is your cycle? What is your moontime like? Do you track your cycle? Do you experience hormone-related symptoms such as acne, bloating, painful periods, PMS, irregular hair growth, etc?

How is your sleep currently? Do you feel like on a day to day basis you are able to recover from the energy you expend?

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

Current Medications and / or Supplements (if any)

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

Do you tend more towards being sluggish or wired when you’re “coping”?

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

homeopathy intake

potenized medicines that align your vital energy.

BE HELD BY HER

HELP

NAVIGATE

CONTACT

beheldbyher@gmail.com
@held.by.her

homeopathy intake

potenized medicines that align your vital energy.

BE HELD BY HER

HELP

NAVIGATE

CONTACT

beheldbyher@gmail.com @held.by.her

beheldbyher@gmail.com
@held.by.her