Client Intake Form .com
Client Intake FormDate _________Name ____________________________________________________________Name of parents or guardians if under 18 ________________________________Address____________________________________________________________________________________________________________________________Phone, Home, _________________Cell________________Work __________________Birth date _____________________Age ______________Emergency contact ________________________Phone ____________________How did you hear about me __________________________________________Current health issues ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Clinical diagnosis _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Medication and herbal supplements _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________Primary Care Physician _____________________Specialty Physician ________________________Medical History.Check all that apply current or pastMental /Emotional____ Hallucinations____ Depression____ Anxiety____ Excessive anger____ Melancholia____ Violence____ Poor concentration____ Poor memory____ Learning difficulties____ Behavioral problems____ Mood swings____ Psychotic episodes____ Greif____ Fears____ Irritability____ Addictions____ Jealousy____ Restlessness____ Suicidal____ History of abuseOther ______Past illnesses/family history ____ Influenza____ Pneumonia____ Mononucleosis____ Measles /Chickenpox____ Ear infections____ Tropical disease____ Lyme disease____ Gonorrhea____ Syphilis____ Tuberculosis____History of antibioticsHow many times ____Other ______Environment: are you sensitive to:____ Barometric changes____ Seasonal changes____ Moon cycle____ Heat____ Cold____ Dampness____ Dry conditions____ Storms____ Wind____ Pollutants____ Smells Other _____ Digestion____ Gas____ Constipation____ Diarrhea____ Changes in appetite____ Hemorrhoids____ Blood in the stools____ Mucous in the stool____ Indigestion____ Ulcers____ Nausea____ Vomiting____ Anorexia____ Bulimia____ Liver conditions____ ParasitesOther ______Habits current or past history ____ Exercise____ Meditation____ Good diet____ Poor diet____ Coffee____ Alcohol____ Cigarettes____ Marijuana____ Heroin____ Cocaine____ HallucinogensOther ______Circulatory system____ Flushes of heat____ Excessive coldness____ Heart attack____ Septic conditions____ Blood clots____ Varicose veinsOther ______Kidney and urinary system____ Cystitis____ Urethritis____ Pain in kidneys____ Pain with urination____ Blood in urine____ Sediment in urine____ Urine retention____ Bed wetting____ Discharge____ Incontinence____ NephritisOther ______Nervous system____ Headaches____ Migraines____ Twitching____ Convulsions____ Contractions____ Numbness____ Incoordination____ Ataxia____ Stroke____ Catalepsy____ Narcolepsy____ Insomnia____ Coma____ Vertigo____ Paralysis____ Visual disturbance____ Pain____ Head injuryOther ______Endocrine/immune system____Diabetes____Irregular hormones____Immune deficiency____Vaccine side effect____Repeated infection____Auto immune Other ______Respiratory System____Frequent coughs____Bronchitis____Difficulty/Painful breathing____Asthma____ExpectorationOther ______Skin____Eruptions____Rash ____Hives____Eczema____Ringworm____Scabies____Lice____Itching ____Infections____Wounds slow to heal____SensitiveOther ______Female____PMS____Bloating____Breast tenderness____Excessive bleeding____Irregular menses____Absence of menses____Menstrual cramps____Fibroids’____Cysts____Prolapse____Discharge____Infection/yeast____Herpes____Pain with ovulation____Irregular pap____PID____Loss of sexual energy____hypersexual____Abortion____Miscarriage____Live births____Birth control pillOther ______Male____Impotency____Premature ejaculation____Painful ejaculation____Epididymitis____Undescended testicle____Prostate condition____Dribbling urination____Discharge____Infection____Herpes____Inflammation____Loss of sexual energy____HypersexualOther ______Musculoskeletal system____Previous injury____Arthritis____Osteoporosis____Inflammation____Weakness____Inflexibility____Pain____Chiropractic____Massage/body workOther ______Other conditions___________________________________________________Complementary and Alternative Health Care Client Bill of RightsIn accordance with The Minnesota Complementary and Alternative Health Care Freedom of Access Act: Chapter No. 460 – House File 3839, as of July 1, 2001, all complementary and alternative health care providers shall provide their clients with a written copy of the Complementary and Alternative Health Care Client bill of rights.In seeking homeopathic care or massage therapy from Kate Birch, RS Hom (NA), CCH, CMT, I understand the following:THE STATE OF MINNESOTA HAS NOT ADOPTED ANY EDUCATION TRAINING STANDARDS FOR UNLICENSED COMPLEMENTARY AND ALTERNATIVE PRACTITIONERS. THE ATTACHED CREDENTIALS ARE FOR INFORMATION PURPOSES ONLY.Any client has the right to file a complaint with the following office: Health Occupations Program, Minnesota Department of Health, 121 East Seventh Place, Suite 400, PO Box 64975, St. Paul, Minnesota 55164-0975. 651-282-6319 or 1-800-652-3957.Fees collected will be according to the attached fee schedule.Clients have the right to complete and current information concerning the practitioner’s assessment and recommended services that is provided including the expected duration of services provided.Clients may expect courteous treatment free from verbal, physical or sexual abuse by the practitioner.Client records and transactions are confidential, unless release of these records is authorized in writing by the client, or otherwise provided by law.Clients have a right to be allowed access to records and written information from records in accordance with Minnesota Statute 144.335.There are other practitioners who offer similar services in the yellow pages.Clients have the right to choose freely among available practitioners and the change practitioners after services have begun within the limits of insurance or other health programs.Clients have the right to a coordinated transfer when there will be a change in the provider of services.Clients have the right to refuse treatment, unless otherwise provided by law.Clients may assert their rights without retaliation.I hereby acknowledge the receipt of the client bill of rights and the attached documents therein, and I have had full opportunity to ask any questions I have about this document and my rights as a client.___________________________________________________________Client SignatureDateHippHealth Center for Holistic Healing612-338-1668612-701-OFFICE POLICIES AND STATEMENT OF FEESKate Birch, RS Hom (NA), CCH, CMTClassical Homeopathy consultationsInitial interview Adult (1? -2 hours)$305 Children (1? hours)$225 CEASE Therapy vaccine injury (1? -2 hrs) $275Follow up consultations:Extended (1 hour, 15 min)$120Regular visit (1 hour)$103Intermediate visit (45 min)$90Brief visit (30 min)$75Phone consultations:Same as above20 min or less$55/ Homeopathic remedy dose$7-8.50 per remedy$25-$45 for liquid Doula servicesBirth Plan, Labor and delivery, post-natal and neonate Cranial SacralCheck for current pricesNutritional counseling, detoxification programs Consulting services (? hour)$75Credit Card service Charge4%For adult constitutional care, expect regular follow up appointments every 4-6 weeks as progress continues. Once health has stabilized follow up every 3-6 months is recommended to maintain one’s health.For children, as they grow and change so quickly, we may need more frequent shorter follow up appointments for the first few months of care. In acute situations, after a scheduled consultation, phone calls over the subsequent days, to manage the condition, are of no charge. Once health has stabilized it is recommended to seek homeopathic care at the change of seasons.For immune system difficulties/vaccine injury conditions in children expect to invest at least 6-8 months of continued care (visits every 4-5 weeks) to stimulate the immune system to begin repairing the damage and clear toxins etc.Phone calls with specific questions, case management issues or concerns between scheduled appointments are no charge unless they become frequently lengthy. Phone calls requiring a remedy are pro-rated at the above rates.Cancellation policy: 24 hour notice. Missed appointments constitute full payment.Office hours: 9:00 am - 6:00 pm Tuesday, Wednesday, and Thursday Saturday by appointmentKate Birch, RS Hom(NA), CCH, CMT.Credentials, Affiliations and AssociationsSept 2013 Research Faculty with the American Medical College of Homeopathy, AMCH, AZFeb 2013 Certified CEASE Therapist (Complete Elimination of Autism Symptom Expression)January 1013 Founding member and Co-director of Free and Healthy Children International (FHCi), a MN based non- profit established to research and promote the use of homeoprophylaxis for infectious disease preventionApril 2012 Rhythmic Movement Training Certificate for integrating infant reflexesJanuary 2013 DONA certified Doula Jan 2011- April 2011 Clinic Supervisor at Northwestern Academy of Homeopathy (NWAM), Minneapolis, MN July 2000 Completion of clinical training at Northwestern Academy of Homeopathy (NWAM), Minneapolis, MNJanuary 2000- Certified Member, CCH, Council for Homeopathic Certification (CHC)August 1998-Registered Member, Minnesota Homeopathic Association (MHA)April 1998 Certified Massage Therapist, CMT, The Colorado School of Healing Arts, Denver CO June 1996-Registered Member, RS Hom(NA), The North American Society of Homeopaths (NASH)June 1996 Practitioner of Classical Homeopathy, Dynamis School of Advanced Homeopathy (DSAH), Devon EnglandAugust 1994 Certificate of Homeopathy, C.Hom, Pacific Academy of Homeopathy (PAHM), Berkeley, CAJune 1991 Associate Science Degree, honors, Santa Rosa Junior Collage, Santa Rosa CASince 1990 Kate has over 2000 hours in homeopathic and clinical education, with an additional 700 hours in massage and bodywork training. She is the author of Vaccine Free Prevention and Treatment of Infectious Contagious Disease with Homeopathy and co-author of The Solution~ Homeoprophylaxis: The Vaccine Alternative. She is respected international teacher and researcher on the subject of infectious disease and homeopathy. She has been teaching homeopathy in lecture and classroom settings since 1994. She has a general practice for men, women and children for all health concerns from infancy throughout life. Kate’s life work is to promote the use of homeopathy as a public healthcare model for infectious disease and to change the vaccine paradigm so that our children can live free and healthy lives. ................
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