Herbalism Group Session Intake Form
I gather the following information so I have some relevant background ahead of our sessions. Please answer the questions to the best of your ability. All information will remain private & confidential and compliant with GDPR.
Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Do you have any medical conditions and are you taking any medications at present? Including the contraceptive pill.
*
Have you recently had any serious medical events that have required hospitalisation or drug treatment?
*
Do you use recreational drugs habitually? Or a history of using habitually? Including tobacco.
*
Have you or any close family members experienced significant mental health challenges?
*
Do you have any known allergies (including medications) or any reason to believe you would be allergic to any plants?
*
Do you have a sensitivity to alcohol? (we will sometimes use tinctures in the sessions, which contain alcohol. Most of the alcohol will evaporate when mixed with boiling water, but let me know if you need to avoid alcohol completely and I can accomodate.)
*
Is there any specific intention/question or theme you would like to bring to the session?
Is there anything else you feel I should be aware of?
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