Bernal Homeopathy Client Intake & Disclosure Form

Today's Date

Date

Client's Name*

First NameLast Name

Parent or Legal Guardian Name if under 18 years of age

First NameLast Name

Date of Birth

Date

Age

E-mail*

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

What is the main problem you are having right now?*

Any family health issues such as cancer, diabetes, depression, alcoholism, etc.? If so, please specify the relation to you, and approximately how old were they at onset of illness, if known:*

Are you on any medications? What is the dosage?*

What are the main improvements you hope for with homeopathic treatment?*

How did you hear about Bernal Homeopathy?*

PLEASE CHARACTERIZE YOUR HEALTH:How is your health (emotional, mental and physical symptoms)? Please outline at least one important change you would like to see as a result of your treatment.*

SYMPTOM #1 Choose one symptom (physical, mental or emotional) which bothers you the most. Then consider how bad this symptom is, over the last week, and score it by clicking your chosen number. This should be your opinion, no one else's.*

score: 0 = as good as it could be...TO...10 = as bad as it could be*

	0	1	2	3	4	5	6	7	8	9	10

0 is Best, 10 is Worst

SYMPTOM #2 Choose a second symptom (physical, mental or emotional) which bothers you the next most. Then consider how bad this symptom is, over the last week, and score it by clicking your chosen number.

score: 0 = as good as it could be...TO...10 = as bad as it could be

	0	1	2	3	4	5	6	7	8	9	10

0 is Best, 10 is Worst

ACTIVITYNow choose one activity (physical, social or mental) that is important to you, and that your problem above makes it difficult or prevents you doing. Score how bad it has been in the last week.

score: 0 = as good as it could be...TO...10 = as bad as it could be

	0	1	2	3	4	5	6	7	8	9	10

0 is Best, 10 is Worst

WELL BEINGHow would you rate your general feeling or wellbeing?0 = as good as it could be...TO...10 = as bad as it could be

	0	1	2	3	4	5	6	7	8	9	10

0 is Best, 10 is Worst

MEDICATION Are you taking any medication FOR THE PROBLEM(s) ABOVE?

Is cutting down this medication:

IF NO: Is avoiding medication for this problem

CLIENT DISCLOSURE Welcome to my practice. As you know, I am a practitioner of Homeopathy. I am not a licensed physician, nor are Homeopathy services licensed by the state. I graduated from the Pacific Academy of Homeopathy in San Francisco, California. I have certification in classical homeopathy from the Council for Homeopathic Certification. The idea behind Homeopathy is that homeopathic remedies, derived from natural substances, when selected correctly shift the body towards health, i.e., prompt the body to better heal itself. The selection of a correct remedy is what I do as a homeopathic consultant, based on the law of similars – that a substance which can cause symptoms in a healthy person can resolve those same symptoms in an ultradilute dose and improve health. The remedy I select will be based on all of the symptoms and characteristics of my client presenting at the time. In order to use my services, California state law requires that you acknowledge receipt of the information provided in this form and that you sign it. You will receive a copy upon request. I will keep the original in my records for at least three years. My method of treatment, homeopathy, is an alternative or complementary form of healing arts. Under Sections 2053.5 and 2053.6 of California’s Business and Professions Code, I can offer you these services, subject to requirements and restrictions that are described fully in the document entitled “California State Senate Bill SB-577 - What It Means for Patients.” If you ever have any concerns about the nature of your treatment, please feel free to discuss them with me. I recommend that you inform your medical doctor that you are receiving Homeopathy treatment, especially if you are under medical care for any condition. Acknowledgement and Consent to Receive Services: I have read and understand the above disclosure about the Homeopathy services offered by Kathleen Scheible and her training and education. I have discussed with her the nature of the services to be provided. I understand that Kathleen Scheible is not a licensed physician and that Homeopathy services are not licensed by the state. I understand it is my responsibility to maintain a relationship for myself/my child with a medical doctor. I have consented to use the services offered by Kathleen Scheible, and agree to be personally responsible for her fees in connection with the services provided to me including 50% cancellation fee for weekdays cancelled in less than 24 hours or in less than 48 hours for Saturdays. THE INFORMATION YOU PROVIDE BELOW WILL REMAIN CONFIDENTIAL AND SECURELY ENCRYPTED BEFORE SUBMISSION. By clicking AGREE, you have electronically signed consent and retained a copy of Kathleen's Client Disclosure form.

I AGREE