Insight Herbalism - Intake Form — EarthStar.Birthing

Insight Herbalism - Intake Form

Name

First Name

Last Name

Date of Birth

Address

Phone Number

GP name and Surgery

Next of Kin (emergency contact details)

Current Medical Conditions / Diagnosis:

Current medications that you are taking (please include supplements and / or herbs):

Have you recently had any serious medical events that have required hospitalisation surgery, or aggressive drug treatment?

Are you pregnant or breast feeding?

Are you on the contraceptive pill or any other form of contraception?

Do you have a high level of (habitual) recreational drug use (including alcohol)? Do you have a history that includes exposure / high use of psychedelic substances?

Do you have (or does anyone in your close family) have experience of serious mental health challenges?

Please give details of any major childhood illness and or trauma that you feel may be relevant:

Do you have any allergies or any reason to believe you may have an allergic response to any plant?

Do you have some experience with holistic healing or working with healing as a process?

How would you describe your connection to nature?

Is there any themes or questions you would like to work with in these sessions?

Any additional information?

Please fill out this form prior to your first session.

All information will be kept safe and confidential. All information will be viewed in a compassionate and non-judgemental capacity. Please fill out as much detail as possible. Any questions you do no feel comfortable with answering can be left out.

Sessions are £70-£45 per hour depending on your personal circumstances.

Bank details for payment: Ms E A Taylor

Account No: 75471809 Sort Code: 60-02-38