Herbal Intake formPlease fill out this form to the best of your ability prior to your appointment! Name * First Name Last Name Date of your appointment * MM DD YYYY Email * Would you like to be added to our email list to receive future updates, promotions, discounts, and details about community events? * Yes, please! No thanks! How did you hear about us? * What is your gender and what are your preferred pronouns? * What is your occupation? * What is your date of birth? * Please briefly describe the landscape of your life-what has brought you to seeking this session or container? * Have you had any recent or memorable life impacting changes ? If yes, please describe. * How would you best describe your current lifestyle? Please briefly describe your diet, your habits (the good, the bad, the ugly), and anything else you feel might be relevant to working with me. * Please briefly describe the kinds of dietary choices, herbal remedies, pharmaceuticals, or lifestyle changes that you have made in the past that have HELPED or HINDERED your healing process. Please briefly describe your mental and emotional health both past and present. Please briefly describe your family history-specifically in relation to accidents, illnesses, environmental toxins exposure, addiction, mental health, and trauma. Please add anything else that you feel may be relevant here. Do you have a connection to spirituality? Please briefly describe your spiritual life here.
