Consultation Form

At Graceful Healing Homeopathy, every journey begins with understanding you. During your consultation, we’ll take the time to listen to your health concerns, lifestyle, and wellness goals so we can create a personalized plan tailored just for you.

Homeopathy offers a gentle, natural approach to restoring balance and supporting long-term wellness. Whether you’re seeking relief from specific symptoms or looking to improve overall vitality, this first step is about discovering the right remedies for your unique needs.

Fill out the form below to request your consultation, and start your path toward safe, holistic healing.

Name

First Name

Last Name

Phone

(###)

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Cell Phone

(###)

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Date of Birth

Age

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Which phone number should we use for leaving messages

Occupation (current or prior to retirement)

Currently Retired

Yes

Spouse/Partner’s Name

Parent’s Names (if client is a child)

Children’s Names & Ages even if adults (sibling names if client is a child)

Medications presently taking and what they are for

What is your chief complaint? Please briefly list the ailment(s).

When did you first have this/these complaint(s), even in a very mild form?

What, if any, diagnosis was made? What diagnostic tests were performed?

Did you consult a health professional? If so, what is their specialty?

Please list any known history of disease in your family such as cancer, heart disease, diabetes, alcoholism, etc. What is your relationship? If deceased, what was your parents’, grandparents’, siblings’ cause of death?

Please list any treatments and/or noteworthy medical events. Specific dates are not important; approximate as best you can.

Disclaimer:

Graceful Healing Homeopathy and Patricia Samler are not physicians, and the relationship between Patricia/Graceful Healing Homeopathy and clients is not one of prescriber and patient, but of educator and client. It is fully the client’s choice whether or not to take advantage of the information presented. Homeopathy does not “treat” an illness; it addresses the entire person as a matter of wholeness that is part of an educational process, not a medical one. For diagnosis or medical treatment, clients are encouraged to seek the advice of a licensed holistic or conventional physician.

I Agree

By clicking on “Submit,” I agree by electronic signature to: (1) receive recurring automated marketing and other communications (including emails, calls, texts, and prerecorded messages) from Graceful Healing Homeopathy at the email address and phone number I provide, even if I am on a “Do Not Call” list (consent is not required to book a consultation; message & data rates may apply; reply STOP to opt-out of texts or HELP for help).