Herbal Consultation Intake Form

Herbal Consultation Intake Form

Herbal Holistic Wellness Minyan Murphy-The Herbal Scientist B.S Forensic Science * M.S Molecular Biology * Master Herbalist
The purpose of this intake form is to clearly outline the responsibilities of both the client and the herbal practitioner as we enter a healing partnership. This form explains what you can expect during the consultation process and clarifies the scope of practice of an herbalist.
The Responsibility of the Herbal Practitioner
My objective is to help you achieve optimal health and vitality in alignment with your personal goals. As a clinical herbalist, I offer holistic wellness guidance to help support your body’s natural balance. I am not a Medical Doctor, nor do I practice western medical assessment, diagnosis, or treatment. I do not claim to cure disease. I do not prescribe, adjust, or give advice regarding pharmaceutical medications at any time.

Herbal medicine is extensive and complex, and must be used responsibly. Some herbs may be contraindicated with certain pharmaceutical drugs. You are responsible for your own health decisions, and it is recommended that you consult with your physician regarding any questions about your medical condition or medications.

I have no objection to clients being seen or evaluated by their personal medical doctor. I am willing to collaborate as part of a health care team that may include physicians and other licensed health providers, when appropriate.

All client records and information shared during consultation are kept strictly confidential, unless you request otherwise in writing.
Client Payment & Service Terms
A one-time payment is due at the time of scheduling and is non-refundable. You may choose from the following consultation options:

$150 – Virtual Herbal Consultation (Feedback + Recommendations Only)
Includes a full intake review, lifestyle & symptom assessment, and a written herbal + dietary plan delivered via email.
$250 – Full Herbal Medicine Consultation (Includes Custom Herbal Formula)
Includes everything above plus a personalized herbal medicine blend prepared and mailed to your address.
Payments are processed when you submit this form. Because custom time, review, analysis, and in some cases medicine preparation begin immediately, no cancellations or refunds will be accepted after the submission of this intake form.

You can refuse to follow any and all recommendations provided as a result of this consultation. You have the right to choose another practitioner for any reason, and to request that any of your health information be disclosed to another practitioner, or healthcare provider.

Follow-Up & Timeline
• A confirmation email or text will be sent once your intake form is received.
• Please allow 7–10 business days for me (Minyan) to review your case and create your personalized wellness plan.
• Your full written protocol — including herbal recommendations, dosage guidance, nutrition suggestions, and lifestyle notes — will be emailed to you for your records.
• If herbal medicine is included in your package ($250), it will be prepared and mailed after your plan is completed.
• Any follow-up questions after receiving your plan may be addressed via email, phone call, or Zoom call.

Your Rights
• You may decline any recommendation at any time.
• You may request that your health information be shared with another practitioner.
• You may choose another practitioner at any time, without obligation.
Health Demographics
Name*

First NameLast Name
Date of Birth *

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What are your major concerns that you want to address?*
When did the symptom(s) begin?*
Have you had a diagnosis? If so, what was it, when and by whom?*
Are you currently taking any medications, prescriptions, supplements or herbs?*
If you are or were on any medications, prescriptions, supplements, or herbs in the past 6 months please list them all and the dosage.*
How often do you take each medication?*
Do you have any infectious diseases that you know of? If so, please list them.*
Are you pregnant?*
If pregnant, how far along?
Do you have any known allergies or sensitivities? If so, please list them:*
Is there any reason why you could not take remedies made in alcohol (tincture)?*
Have you ever been hospitalized or had any surgeries? If so, please note date and reason:*
Any known family medical history problems from living or deceased?*

Side Effects, Toxicity, Herb-Drug Interactions and Herbal Regulation

The historical record and modern research indicate that the herbs most often used for healthcare have an exceptional safety record. The most common issues associated with herbs are negative herb/drug interactions. I understand the importance of notifying my practitioner of any additions or changes in my prescription medication regime.

Herbs and supplements are regulated by the Food and Drug Administration, under the category of foods.

Most states, including Florida, do not license Herbalists. Therefore I am not licensed, but fully disclose the nature of my practice.
By signing this document I waive any claim for compensation or liability on the part of the herbalist beyond what may be offered freely by the herbalist in the event of such injury, death or medical expenses incurred by me or others.

I acknowledge I am fully responsible for following the recommendations provided by the practitioner and for sharing these recommendations with my primary doctor.

I understand that Minyan Murphy is not a licensed physician and therefore cannot diagnose or treat disease, or prescribe drugs.

I certify that I have read this document, and I fully understand its content. I am aware that this is a client-practitioner agreement and release of liability, and I sign it of my own free will.
Signature*

Clear
Date*

MonthDayYear
Date

My Products

Herbal ConsultationHerbal Plant Medicine Included

$250.00

Herbal Consultation Herbal Medicine Not Included General recommendations and feedback

$150.00

Enter coupon

Total

$0.00

Payment Methods

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Herbal Consultation Intake Form

Health Demographics

Personal Health Traits

Health Concerns