Schedule An Appointment

Schedule An Appointment
Basic Information
Name*

First NameLast Name
Email*
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Phone Number*
Please enter a valid phone number.
Address*

Street Address

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CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Current Age*
How did you hear about Seeking Shalom - Emotional Healing?*

FacebookGeneral web search found this websiteReferred by someone (please enter their name in the Other section below)Other

Services
Bach Flower Consultations
- $50* Initial Consultation includes personalized remedy bottle
- $25*/half our Follow-Up Consultations include personalized remedy bottle
ZYTO Biophysical Feedback Scans
- $25* Full Biophysical Scan includes Wellness Report +$5 for additional reports
- $10* Food Scan includes Main Foods Report + Food Descriptions Report
LimbicArc
- $100 monthly subscription
- Do a Spark Scan as often as once every 24 hours
- Run up to 5 infoboosts simultaneously, selecting from over 800 ingredients
- Add up to 8 friends and family for only $10/month each
LimbicArc + CERT (Cook's Emotional Release Technique)
- $150 monthly subscription
- Do a Spark Scan as often as once every 24 hours
- Run up to 5 infoboosts + 1 CERT infoboost simultaneously, selecting from over 800 ingredients
- Add up to 8 friends and family for only $10/month each (includes CERT for free
* Payment in full is required via PayPal or cash prior to appointment.
What service or services are you seeking? (Select all that apply.)*

Bach Flower ConsultationZYTO Biophysical Feedback ScansLimbicArcLimbicArc + CERTOther
Please give the top 3 reasons for your visit, in order of priority.*
Do you have any questions you would like addressed at your appointment?*

Nutrition
How many ounces of water do you drink each day?*
What kinds of water do you drink the majority of the time?*

Municipal water supplyWell waterSpring waterBottled waterOther
What other beverages do you drink daily and how many ounces of each?*
Do you use artificial sweeteners? If so, which ones? How often and in what?*
Do you eat breakfast? If so, what do you eat for breakfast?*
How many fresh fruit do you eat per week?*
How many raw vegetables servings do you eat per week?*
How many fermented foods do you eat per week?*
How many fast food meals do you eat per week?*
How many servings of meat do you eat per week?*
How many eggs do you eat per week?*
How many dairy servings do you eat per week?*
What foods do you crave?*
What foods do you dislike the most? Why?*
What time of day do you eat your first meal?*
What time of day do you eat your last meal?*
Which meal is the largest meal of the day?*
Describe a typical "largest meal".*

Movement
What is the first thing you do when you get up in the morning?*
Do you exercise/move/participate in a fun sweaty activity? If so, what and how often? Do you look forward to it? How do you feel when you are finished?*

Sleep
What time do you go to bed?*
How long do you sleep?*
Do you wake often? If so, why and how often?*
Do you feel rested when you wake up for the day?*
Do you have pain when you first get up? If so, where? Does it go away after moving?*

Eliminations
Do you have daily bowel movements? If so, how many?*
If you don't have daily bowel movements, please describe your elimination pattern.*
Using the Bristol Stool Chart provided below, please indicate the most descriptive Type number(s) and color of your elimination(s).*

Females
Please describe where you are now.

Post-menopausal (you have had 12 or more consecutive months without a period)Peri-menopausal (you are going through menopause)Pre-menopausal (menopause has not yet started)Other
If you are post-menopausal, at what age did you complete menopause?
If you are peri-menopausal, and what age did you start menopause?
If you are post- or peri-menopausal, what were/are the characteristics of your menopausal experience?
If you are pre- or peri-menopausal, are you currently pregnant or do you plan to become pregnant?
If you are pre- or peri-menopausal, are you currently using any contraception? If so, what kind?
If you are post- or peri-menopausal, please describe your menstrual cycle here. Is it regular? How long is your cycle? How long is your flow? Do you experience cramps or clotting? Is your menses more red, purple, or brown? Do you experience PMS, cyclical headaches, or cravings?
Are you currently taking Hormone Replacement Therapy (HRT)?

Supplements / Medications
Do you take any supplements? If so, which supplements, how much, how often, and what for?*
Do you take any OTC medications regularly (such as Aleve or Aspirin)? If so, which OTC medications, how much, how often, and what for?*
Do you take any prescription medications (prescribed by a licensed medical professional)? If so, which prescription medications, how much, how often, and what for?*

Features
Picture of Your Face

Please take a frontal picture of your face without a smile.
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Picture of Your Eye

Please take a close-up picture of your eye.
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Picture of Your Tongue

Please take a picture of your tongue. Stick it out and relax it before taking the picture.
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Medical History
Have you had any surgeries? If so, what surgery and when?*
Have you received any diagnoses from any licensed medical professionals? If so, what diagnoses and when?*

Naturopathic History
Have you ever been in consultation with a Naturopath? If so, why and how long ago? What was suggested? Did you experience a good outcome? What did you like about it? What was not as successful for you? *
Do you have regular adjustments with a chiropractor?*
Do you have regular body work/massages?*
Please check each item with which you are familiar?*

HomeopathyAromatherapyMuscle response testingGalvanic skin responseQuantum physics energyBach Flower remediesProbioticsHerbalsEnzymes

Scheduling My Appointment

Please select your top 3 choices for your appointment.
Appointment - Choice #1*
Appointment - Choice #2*
Appointment - Choice #3*

Signature
By signing and dating below, I certify that the information I have provided in this application is accurate. I also understand that I am responsible to make payment in full prior to services provided. I also understand that I am here to learn about natural health practices, that I will be offered information about whole food, supplements, herbs, homeopathy, flower essences, enzymes and more, as a guide to general good health. I acknowledge that this is a personal ministry offering spiritual counseling and personal empowerment. I fully understand that those who counsel me are not medical doctors and I am not here for medical diagnostic purposes or treatment procedures. I am not on this visit, or any subsequent visit, an agent for federal, state, or local agencies or on a mission of entrapment or investigation. The services performed here are at all times restricted to consultation on holistic wellness matters intended for the maintenance of the best possible state of natural health, and do not involve the diagnosing, treatment, or prescribing of cures for disease or medical conditions.*

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Basic Information