CLIENT
INFORMATION
First and
Last Name
Your Email
Check for accuracy!
This form will only submit
with a valid email address.
Name
of Person(s) for homeopathic care
Age(s)
of Person(s) for homeopathic care
Phone(s)
Please provide your home, work,
and/or cell phones.
Skype
address (For free internet phone and video conferencing with our
homeopaths.)
I f you do NOT have a skype address for
free internet phone and video conferencing, write N/A.
Best Time(s)
for Consultation
Your Complete
Mailing Address:
Include all:
Address,
City, State & Zip Code
Select
your country or geographic area from this list.
USA
AFRICA
ASIA
AUSTRALIA
CANADA
CENTRAL/SOUTH AMERICA
EUROPE
INDIA
MIDDLE EAST
OTHER
Have you ever used homeopathy
previously?
YES
NO
If YES , please give the name
your homeopath(s) below. If NO or you can't
remember the name, just write N/A.
TYPE OF CHRONIC
ISSUE
Type of homeopathic care you
are requesting?
Please choose only one.
CHRONIC CARE: 1 - 3 months issues
CHRONIC CARE: 3 - 6 months issues
CHRONIC CARE: 6+ months issues
What ISSUE are you
most interested in
homeopathic care for?
Scroll down to find the best
match.
Please select the One (1) Main Health Concern
that applies to the person(s) you are seeking help for.
You may
explain more details about other family members for whom you
may be seeking care in the Comments section below.
Please choose only one.
Adverse Reaction to Recent Vaccine
Allergies (Chronic & Seasonal)
Asthma
Alcoholism/Drug Addiction
Anxiety/Panic Attacks
INFANT: for homeopathic care
Breastfeeding Problems
Cancer
CHILD: with autism, ADD/ADHD, SPD, etc.
CHILD: for homeopathic care
Chronic Fatigue Syndrome (CFS)
Constipation (chronic)
Death of a Loved One
Depression (more than 3 months)
Ezcema, Skin Rashes (chronic)
Fibromyalgia
Gastro-Intestinal Issues
Grief or Emotional Trauma
Graves Disease
Infertility and Conception Issues
Labor and Birthing
Lyme Disease
Mental Health/Emotional Issues
Menopause, Hot Flashes, etc.
Miscarriage(s)
Morning Sickness
Neurological Issues
Pregnancy Related Issues
Premenstrual Syndrome (PMS)
Postpartum Depression
Thyroid Issues
Stress - Chronic
Vaccination Damage (past)
Yeast Infections (Repeating)
Other Health Issue (specify in comments)
Select the name of person you
request contact from using this list.
For ACUTE CARE please
do not use this form. Instead,
complete the
ACUTE CARE
FORM .
If you do not have a
preference, select
FIRST AVAILABLE HOMEOPATH.
If you are not sure which
Homeopath to consult with, select
KARI J. KINDEM,
DIRECTOR.
FIRST AVAILABLE HOMEOPATH
KARI J. KINDEM, Director
DEBORAH LICURSE - New York
KIM PURDY - Massachusetts
GAIL WILSON - California
ADDITIONAL COMMENTS
Comments: Please provided us with more details on the nature of your inquiry
so we may best assist you. Please limit what you write to a maximum size of the space provided.
You must add a comment in
any length to submit this form.
How
did you find out about Homeopathy for Women?
Please choose only one.
Google Sponsored Ad
Google search
Yahoo search
Internet search
www.HomeopathySNC.org
www.HomeopathicConstitution.com
Homeopathy For Women Blog
Parent of Special Needs Child
Other Homeopathy Website
Referred by a Homeopath
Referred by a Family Member
Referred by a Friend
Other
If you are a REFERRAL, please provide the
name of the person who referred you to us.
N/A.
Please
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