Homeopathy Help Network - Homeopathy Help Network

Consult Type

Type of Consult Requested*

Chronic Consult Practitioner Tiers*

What level of Homeopathic Practitioner are you interested in? Sometimes student practitioners are not available so please select any options that you are interested in.

AHE Student Practitioner Under Supervision: $150 / $40 Follow ups
AHE Graduate (non-certified): $200 / $60 Follow ups
Certified Classical Homeopath: $250 / $75 Follow ups

Your Availability*

The clinic is open from 9am-6pm Eastern, Monday-Friday. We can take cases anytime during these hours. However, we have students participating in the acute clinic training from 3-5 pm ET Monday-Friday which you may scheduled for. Can you be available for a 30-minute consult during that time?

Yes, 3-5pm EASTERN today or tomorrow works!
No, 3-5pm EASTERN doesn't work well.

Contact Information

Your Name*

First Last

Your Email*

Your Phone*

Are you the one needing care? - Adults (or parent if a minor) must sign Consent Form below*

Yes
No

Your relationship to the client:*

Does the client know you're contacting Homeopathy Help Now on their behalf?*

Yes
No

Client Name*

First Last

Client Phone*

Client Email*

Client Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Client Date of Birth*

Client Gender*

Male
Female
Trans

Preferred Method of Client Communication

Online Video Conference
Phone Call

How did you hear about us?

Health Information

Date Symptoms Began*

Please briefly list what you are experiencing.*

Pre-existing Conditions*

Have you (the client) been vaccinated for CV19?*

Yes
No

Which COVID-19 vaccine did you get?*

Have you been tested for COVID-19?*

Yes, I'm positive now
I previously tested positive
I have not tested
I've tested COVID negative

Current or Recent Medications & Labwork*

Is the client familiar with homeopathy?

Yes
No

Does the client already work with a homeopath?*

Yes
No

Does the client have access to homeopathic remedies at home or locally?*

Yes
No

Are you requesting a specific practitioner on our team?

Have you been referred to our organization from a specific place or person?

Sliding Scale Fees

Sliding Scale Consult Fee*

To fund the non-profit work of HOHM Partners Foundation to provide free and low-cost homeopathy care, we ask that if you can afford to pay $40 for the single consult that you select that option below. There are also other sliding fee options for those who need financial assistance. The vendor for the charge will show as HOHM Partners.

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Total

$0.00

Read the consent and continue to the bottom to sign and submit the form.

Agreement for Consultation

Our work together

Homeopathy views health from a holistic perspective. Homeopaths do not make any sort of diagnosis in medical terms and it is your responsibility to maintain a relationship with a licensed physician or primary care provider for appropriate evaluations and check-ups.

***Under no circumstances should any suggestions be taken as a medical diagnosis or direction against a licensed medical or mental health care professional.***

By agreeing to our terms of service you agree to the following:

I understand that the goal of homeopathy is to increase my (my child’s) general vitality and constitutional strength and that no specific disease will be diagnosed or treated.
I authorize discussion of my case notes with other professional Homeopaths if my (my child’s) best interests are served by such a consultation. My right to privacy will be protected by withholding my name and any other identifying information.
I am over 18 years of age and have voluntarily chosen homeopathy support for myself/my child.
I am aware that that the outcome and duration of homeopathy support vary by individual and cannot be guaranteed. And that the assigned Homeopath further offers no warranty or guarantee as to the outcome of the homeopathy support.
I agree that I have a choice with regard to where I obtain homeopathic remedies recommended.
I understand that these services are being provided on a donation basis, and I am under no obligation to pay a fee for the services provided for the acute condition I am receiving a consultation for.
I am aware that my assigned Homeopath is working on a voluntary basis and as such, I waive all legal rights that may arise from the homeopathy support and hold the assigned Homeopath harmless from all claims, present and future, known or unknown, in any manner arising out of the homeopathy support.
This Agreement shall be governed by the laws of the State of Arizona and the venue of any action brought concerning the interpretation or enforcement of this Agreement shall be proper in the county the Homeopath resides.
The Parties agree that the terms and provisions of this Agreement embody their mutual intent and that such terms and conditions are not to be construed more liberally in favor of, or more strictly against, either Party.
If any provision herein is invalid, it shall be considered deleted from this Agreement and shall not invalidate the remaining provisions of this Agreement.
I understand that the Homeopath I will be scheduled with is not a medical doctor and does not diagnose. All recommendations are for wellness and overall health building purposes.
As a homeopathy teaching clinic, we are ethically required to recommend public health guidelines. We can still provide support; however, our practitioners will suggest testing. If your symptoms change such that you need medical evaluation before continuing further remedy support, this will be clearly communicated to you. We firmly believe it is a person's right to make their own decisions, but we are also bound by certain guidelines when providing recommendations

Client Consent & Signature*

I verify that I have read and understand the terms of service outlined on the Terms of Service page.

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Are you or a loved one
sick and need support?

Homeopathy Consult Appointment Form

Consult Type

Contact Information

Health Information

Sliding Scale Fees

Agreement for Consultation

Our work together

Are you or a loved one sick and need support?

Homeopathy Consult Appointment Form

Consult Type

Contact Information

Health Information

Sliding Scale Fees

Agreement for Consultation

Our work together

Are you or a loved one
sick and need support?