• Child Intake Form

    up to 21 years
  • Format: (000) 000-0000.
  • Childs Birthdate
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Is the child taking any medication/s?
  • Has your child experienced any of the following:

  • Prenatal History

    Mothers Health During Pregnancy
  • Are any of the following ailments present in your family history:
  • Has the child’s mother had any occurrences of miscarriages, stillborns or abortions?

  • If yes please describe

  • Has the child’s mother ever had any difficulty conceiving (e.g. infertility, ectopic pregnancies):

  • If yes please describe

  • Was the pregnancy planned
  • Please place a check any of the following pregnancy complications that occured
  • Did the mother smoke during pregnancy
  • Did the mother use drugs or drink during pregnancy

  • If yes, how much/or what drugs

  • Did the mother have any infections (e.g. colds/flus/vaginal infections etc.) during pregnancy?

  • If yes, please give details

  • Birth and Beyond

  • Delivery
  • Please check beside any of the following conditions that applied to your baby at birth
  • Was the child breastfed

  • 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?

  • Compared to others in the family, the child’s development was
  • Does your child have difficulty sleeping?

  • 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 hours)

    up to age 21: $100

    Follow-Up Visits (45 Minutes)

    $50

    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

     

  • Patient Consent Form

  • About the consult:

    During your consultation, I’ll ask you various questions about different aspects of your life. I will ask you about your family history, your childhood and even your food cravings. We may also touch on your peak or low energy times of the day, and so on. Don’t feel alarmed; there’s a reason for this thorough approach.
    Homeopathy is gentle and subtle. In some cases, a remedy can work within minutes, especially for acute cases. However, in other instances, it may take some time.
    It’s also important to note that in some cases, old symptoms may resurface. This could be a rash from when you were five, for example. Don’t panic; this is a positive sign.

    I’m excited to work with you!

  • Read the following and sign bellow to agree:

    I have disclosed all the relevant information applicable to this consultation and my health status at this point in time. I consent for the information provided to be used by my Therapist and for my therapist to liaise with appropriate health professionals.

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

    I understand all information disclosed is confidential and may not be revealed to anyone without written permission, except when disclosure is required by law.

    I understand that only necessary information is collected and the storage, retention, and distruction of your personal information complies with the esisting legislation and privacy protection protocols. 

    I understand payment is due upon time services are provided unless other arangements have been made prior to the appointment. 

    I understant payment for Initial Intake is $100 and Follow ups are $50. I will confirm with my homeopath on how to send payment.

     

  • Should be Empty: