Children’s Intake Form

 
  • Contact Information

    All client information is private and confidential.
  • Parent Information

  • Child's Personal Details

  • ie. rashes, premenstrual pain, sleeplessness/insomnia, shortness of breath, migraines, constipation, dyspepsia, cystitis, incontinence, infections, coughs, colds... etc
  • ie. asthma, hypertension, diabetes, arthritis, cancer, heart disase, ulcers... etc
  • Diet & Lifestyle

  • Personal Health Concerns

  • Terms of Service

    Before submitting your client intake form, please read the Terms of Service below.
  • The Healing Process

    Please be aware that recovering from a chronic, complex illness requires a commitment of time, energy, and resources. Progress can often be cyclical rather than linear. You may experience periods throughout your treatment where your improvement plateaus. This is normal. It is important to continue treatment through these cycles to achieve a successful outcome.

    Herbal Medicine & Supplements

    The natural medicines used in our clinic can only be prescribed by qualified practitioners and are evidence-based, low reactive formulas that are of the highest quality. We cannot guarantee results with ‘similar' products purchased elsewhere.

    Cancellation/No Show Policy

    We require 24 hours notice should you elect to cancel or reschedule an appointment. If you fail to attend a scheduled appointment without notice then the full cost of the session will be charged.

    By filling out the required information, you agree that you have read and accept the above terms of service.