Intake Form


Please take a little time to answer the following questions. The answers will help me make the best decisions about herbs and remedies that can support you. I know that I am asking a lot of personal and potentially sensitive information. Thank you in advance for sharing and please know that all information is confidential and only for my herbal use.

Date *
Date
Name *
Name
General
How many bowel movements per day? Is it ever difficult or painful?
What is your typical bedtime? Average hours of sleep per night? Do you wake feeling rested?
Work // Health // Family & Friends
Are you satisfied with your energy levels? *
If yes, what time?
If you menstruate, how would you describe it? (Length, amount, how does your body and you emotions feel before, during and after?)
Mostly looking to figure out if you are abstaining from alcohol, are sober, think you experience substance misuse etc. as that will inform what kind of remedies I put together. Let me know if you are sober and if that means you do not want any alcohol based remedies. I work in a harm reduction model and fully support wherever people are at, including intentional psychedelic use if that is something that is supportive to you.
Past & Current Medical History
Have you ever had any of the following? *
Please check anything you have noticed in the past year? *
Name // When Used // For What Reason
Date // Event
Food, Eating Habits, Herbs & Supplements
Name of Supplement // Dosage & Frequency // For What Reason?
Connection & Self-Care
Conclusion

Thank you for taking the time and sharing. Looking forward to our work together!