Veritas Botanica Clinical Intake Form

Name

First NameLast Name

Phone Number

Please enter a valid phone number.

Referral Code (if you have one)

What is the best email to send links and information to?

Birthday

Date

My Products

Intake AppointmentThis is payment for initial consult to establish care and the first protocol. Labs and herbs are not included.

$295.00

Total

$0.00

Credit Card

Are you interested in lab testing and diagnostics? (Hormone panels, food allergy testing, metabolic testing, heavy metals, autism and chronic fatigue panels, mold and Lyme panels, etc?)

Do you feel that you are basically healthy? What are your main concerns and what can I help you with?

What are your goals and what do you wish to accomplish?

Disease and symptoms are the bodies way of telling us that something about our lifestyle is seriously out of balance. Disease can not be healed unless the five pillars are first corrected. The five pillars are: Diet, water, exercise, sleep and mental emotional health. Herbs, supplements and medication are secondary to the five pillars. Are you ready to commit to changing your life style? Are you willing to take full responsibility for your health?

Please describe what your diet is like. What foods have you eaten in the past few days? Do you feel you eat for well being? Is food medicine or is your food toxic?

Describe your fluid intake? Do you drink soda? Coffee? If so, how much? How much water are you consuming?

Describe your sleep patterns.

Do you exercise? How much and what type?

How many bowel movements do you have a day? Do you sometimes go a day without having a bowel movement?

Symptoms are the body's way of intelligently communicating to us that something is wrong. They should never be suppressed. Instead, we use them to learn what the body needs and what message it is sending us. Please check a box for the following symptoms?

	In the past	Never	Sometimes	Frequently
Fevers, night sweats
Headaches
Eye trouble
Dizziness
Irritability
Mood swings
Trouble coping with stress
Depression
Anxiety
Insomnia
Allergies
Sinus issues
Asthma or lung issues
Blood pressure issues
Heart problems
Low or high thyroid
Liver issues
Varicose Veins
Frequent colds and flu
Swollen lymph nodes
Bladder pain, UTI, IC
Kidney trouble
Constipation
Diarrhea or IBS
UC or Crohns
Gas
Bloating
Acid reflux
Stomach ulcer
Diabetes
Body tingling
Nerve damage
Arthritis
Skin issues
Tired after eating sugar
Tired after eating fat
Tired but wired
PMS or PMDD
Fatigue
Root canals or cavities
Gum problems

Please briefly describe your home life. Peaceful or stressful? Is the environment conducive to well-being or does it enable toxic patterns and pitfalls?

Briefly describe your line of work and if you feel you are fulfilled and living in your highest creative purpose

Briefly describe your relationship with substances. Do you use food, alcohol, cigarettes, sex or shopping to cope with stress? Do you need help learning healthy coping tools?

Please list any past hospitalizations or surgeries

Please list any current medications.

Please list all supplements you are currently taking.

Have you received the Covid vaccine or any other vaccines in the past 15 years?

Please list any known allergies

For women, please describe any hysterectomy, procedures, traumatic births or abortions. Please briefly describe your period cycle and any PMS symptoms or menopausal symptoms. Are yo on birth control?

For men, please briefly describe any issues with erectile dysfunction, balding, prostate, or low testosterone.

Herbal medicine is not like a Western drug. The herbs take time to work. Are you willing to be patient and consistent with the therapies? Do you understand that there are life changes required to be made by you, alongside the herbal treatments?

PLEASE READ THIS CAREFULLY. If you are coming to work with me because of chronic health conditions and troubling symptom presentations, please understand that it will take some time to bring the body back into balance. This is a different approach to healing than what doctors do. Unless you are coming to me for a simple particular concern, understand that this in in-depth work we are embarking upon. The protocol might need adjusting. It is common that people need continued guidance. We will need to access your reactions and followup together. People have many questions arise as they begin to implement the protocol and start making changes. When those questions come up, it is important to touch base with me in 30 or 60 minute follow up consultations. Do you see the value in this kind of relationship and are you ready for this kind of commitment and journey? TYPE YES OR NO.

PLEASE READ. Unlike doctors, I make myself regularly available through Facebook messenger and text. You will have questions and updates as you start your protocol. Though I am available to answer simple questions through technology, longer health inquiries need to be addressed in follow-up consultation. I will direct longer health emails and texts back into the therapeutic setting. This is to protect your needs, my time, and to prevent miscommunication and potential danger. Do you agree that we address your questions and concerns in 15, 30 or 60 minute follow up consultations?

WAIVER. I understand that therapist: Caitlin Woolery, is not providing medical services. I will not consider anything she says to substitute in any way for consultation, diagnosis and treatment by a licensed primary health care provider, such as an M.D. Therapist: Caitlin Woolery, is not a licensed medical doctor (M.D.) or a licensed primary health care provider. Persuent to Business and Professional Code 2052, Caitlin is legally allowed to offer health therapy and counseling as a licensed Holistic Health Practitioner (HHP) and as a certified clinical herbalist (CCMH). She does not diagnose, prescribe, or treat symptom, defect, injury or disease. The appointments are for education purposes only. If I want medical advice or treatment, I am encouraged to consult with a licensed primary health care provider. I consult with therapist: Caitlin Woolery, in her capacity as a holistic health counselor who conveys self-help information that people can use to increase their own health and well-being. I affirm my right to self-health and I take full responsibility for my healing process. While Caitlin is here to guide, facilitate and teach, no one knows your body better than you.

WAIVER: 24 cancellation policy applies to all scheduled appointments. Last minute emergencies are not reimbursed but the charge can be applied to the rescheduled appointment.

WAIVER: I come to Caitlin Woolery with the purity of purpose of seeking more information. I state that I do not come with any forethought or desire of entrapping therapist: Caitlin Woolery, into an illegal statement. If I am a member of the AMA, the F.D.A. or any law enforcement agency, or any city, county, state of federal regulatory agency, then I will identify myself as such before the appointment begins. I live in a country founded on freedom and self-determination, and dedicated to life, liberty and the pursuit of happiness. I affirm my right to self-health and the ability of my own innate intelligence (my body-emotion-intellect-spirit) to control my self-healing process. I can heal myself, and maintain holistic health solely through myself/my God/ or my own personal use of other “greater” powers of life that help me to help myself, or through such legal channels as my licensed doctor.