Adult Intake Form Logo

  • Child Intake Form

    up to 18 years
  •  - -

  • Prenatal History

    Mothers Health During Pregnancy

  • If yes please describe

  • If yes please describe

  • If yes, how much/or what drugs

  • If yes, please give details

  • Birth and Beyond

  • If yes, for how long?
    was it easy or difficult?
    if formula fed, what kind and how long   

  • When did the child start on solid foods?
    What was given?

  • what makes your child angry?
    Does your child get angry often/easily?
    Does your child experience uncontrollable rage?   
    Does your child have difficulty expressing anger?   

  • what makes your child sad?
    Does your child cry when sad?
    Does your child cry often/easily?   
    List major experiences of grief/loss in your child’s life   

  • Does your child have any fears?

  • Services and Fees

    Initial Assessment (1.5 - 2 hours) Includes consultation and remedy
    One-time fee: $160
    Fee applies again if treatment is restarted after 1.5 years

    Follow-Up Visits (45-60 minutes)

    Children age 10 and under: $55
    10 and over: $70

     

    Follow-up visits are recommended monthly for the first six months to ensure effective and efficient progress. 


    Additional Fees: any delivery or courier charges are extra

    if a detox package is needed that is not included in the price of the initial assesment, i can provide a variety of detox remedies but some may need to be ordered from other sources. 


    Acute Care Services:

    Two options available 

    Option 1:  One time online/or phone 15-30 minute session: $30 

    Option 2: Initial online/or phone session (15-30 minutes) + a week of daily check ins and updates, if needed, new remedies can be given as you move through the acute illness: $90

    Communication:

    Email updates regarding your progress are encouraged and responded to at no additional charge.
    If further information is needed beyond what can be addressed via email, I may request a phone or in-person consultation, charged at the usual rate.

  • Patient Consent Form

  • I         understand that homeopathy is a system of medicine which offers a holistic and individualised approach to health by: assessing health concerns with a comprehensive intake, carefully evaluating mental, emotional, and physical symptoms. Clients will be asked about their temperament, personal habits, and likes/dislikes. Providing this information is essential to the case and helps the homeopath understand each client as an individual to be able to advise the proper care needed. The goal of homeopathic treatment is to strengthen the constitution of the whole person, resulting in alleviation of symptoms and overall increase in health.

  • Additional Information:

    Nature of Homeopathic Treatment:

    Homeopathy uses highly diluted substances to stimulate the body's self-healing mechanisms. Remedies are chosen based on the totality of symptoms and individual characteristics.


    Duration and Frequency of Treatment:

    Homeopathic treatment is a process that may require multiple consultations over a period of time. The frequency of visits and duration of treatment will vary based on individual health concerns and response to remedies.


    Potential Risks and Side Effects:

    Some clients may experience a temporary aggravation of symptoms after taking a homeopathic remedy. This is usually a positive sign indicating the remedy is working.
    Any unusual or prolonged aggravation should be reported to the homeopath immediately. To stop the aggravation, stop taking the remedy and get in touch with your homeopath. If it was the “wrong” remedy, there would be no reactions in at all.


    Integration with Other Treatments:

    Homeopathy can often be used alongside conventional medical treatments. Clients should inform both their homeopath and primary healthcare provider of all treatments they are receiving. Clients should not discontinue or alter any prescribed medications without consulting their primary healthcare provider.


    Confidentiality:

    All information shared during consultations is confidential and will not be disclosed without the client's written consent, except as required by law.


    Client Responsibilities:

    • Clients are expected to provide complete and accurate information about their health and medical history.
    • Clients should follow the homeopath’s advice and attend scheduled appointments.
    • Clients should inform the homeopath of any changes in their health or circumstances that may affect treatment.

    Cancelation Policy

    Our goal is to provide quality care to all our patients in a timely manner. You will receive a conformation email/notification 4 days prior to your appointment. If there is no response or confirmation your appointment will be cancelled automatically. No-shows, late arrivals, and cancellations inconvenience not only our providers, but our other patients as well. I understand that sometimes, unexpected delays can occur, making schedule adjustments necessary. If you need to cancel your appointment, i respectfully request at least 48 hours’ notice.

    • Any cancellation or reschedule made less than 48 hours will result in a cancellation fee. The amount of the fee will be equal to the price of initial appointment $190.
    • If you are more than 30 minutes late for your service, i may not be able to accommodate you. In this case, the same cancellation fee will apply. We will do our very best to reschedule your service for another time that is convenient to you.
    • In the event of a true, unavoidable emergency, all or part of your cancellation fee may be applied to future services.


    Receiving remedies

    The cost of the first homeopathic remedy is included in the initial appointment price, but any additional remedies are not. Once a remedy is chosen, i will order and send the remedy to you along with instructions of use. If you live outside of Canada, we will discuss an appropriate way of getting you the remedy. Remedies vary in price due to the nature/source of the remedy and can vary from $10-$20. Patients within Red Deer area, can obtain remedies straight from Alchemēa Homeopathy. The cost of shipping remedies is not included. 

    Zoom Appointments

    For patients who wish to do so, cases can be taken via zoom. You will receive an email link of the zoom meeting prior to your appointment, please keep an eye on your email for the notification. If, for some reason you did not receive a notification check your junk mail, if you still don’t see a notification please call/email and we will send another. If agreed upon, recording of an appointment is useful. It can allow for the practitioner to be fully present during your appointment allowing them to make their detailed notes at a later time.

    Payment

    Payment for your session is due upon the time services are provided. Inability to make the payment at this time will result in the cancelation/or rescheduling of your appointment. Payment can be made via cash or E-Transfer to homeopath.darian@gmail.com

    Emergency Situations:

    Homeopathic treatment is not a substitute for emergency medical care. In case of a medical emergency, clients should seek immediate assistance from conventional healthcare providers or emergency services.

  • I,         , have read and understand the information provided above. I have had the opportunity to ask questions and receive satisfactory answers regarding homeopathic treatment. I consent for my child      to receive homeopathic care from Alchemēa Homeopathy and agree to the terms outlined in this form.
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