Consultation Request-Chronic

Please use the Google Chrome browser to complete this form to request a consultation:

"*" indicates required fields

Chronic Consult Practitioner Tiers

Chronic Consult Practitioner Tiers*

Please select any practitioner levels you are open to working with. At times, student practitioners may not be available, so choosing multiple options can help ensure timely care. ***For cases involving multiple or complex medical conditions, a Senior Practitioner may be required. Senior Practitioners have advanced experience in managing more intricate health concerns, including multiple diagnoses, medications, and treatment plans. If necessary, your case may be referred to a Senior Practitioner to ensure you receive the most appropriate care.***

AHE Student Practitioner Under Supervision: $150 / $40 Follow ups

AHE Graduate (non-credentialed): $225 / $60 Follow ups

Credentialed Homeopath: $275 / $75 Follow ups

*If cost is a barrier, you may be eligible for support through our financial aid program.

Follow Ups*

Your commitment to following up when working with a student practitioner allows us to offer you excellent homeopathic care at a reduced rate. Student practitioners need a minimum of two follow ups with each client to fulfill clinical requirements and to ensure the best care. If you prefer not to agree to two follow ups, please request a different level of practitioner.

I agree to a minimum of two follow ups

Contact Information

Your Name*

First Last

Your Email*

Your Phone*

Are you a current or incoming AHE student, or related to an AHE student?*

Yes

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

Yes

Your relationship to the client:*

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

Yes

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

Gender Non-Conforming/Diverse

Preferred Method of Client Communication

Online Video Conference

Phone Call

How did you hear about us?

Are you or your family currently working with a practitioner on our team?

yes

If yes, please provide the practitioner's name below:

Health Information

Date Symptoms Began*

Please briefly list what you are experiencing.*

Pre-existing Conditions*

Current or Recent Medications & Labwork*

Is the client familiar with homeopathy?

Yes

Does the client already work with a homeopath?*

Yes

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

Yes

Are you requesting a specific practitioner on our team?

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

Deposit

A $25 deposit is required to submit your request. This amount will be applied to your consultation fee.

Deposit

Price:

Total

Credit Card

Cardholder Name

Card Details

Agreement for Consultation

Consent (Please scroll to read)*

Our work together

• Homeopathy Help Now (HHN) is an initiative of HOHM Foundation and provides access to safe and affordable homeopathy care while engaging in outcomes-based clinical research in conjunction with The Academy of Homeopathy Education.
• Homeopathy views health from a holistic perspective. Homeopaths do not make a medical diagnosis. 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 suggestions be taken as a medical diagnosis, nor should recommendations be seen as direction against a licensed medical or mental health care professional’s advice.

By agreeing to HHN’s 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 homeopaths and/or health care professionals should assistance in remedy selection and/or case analysis be necessary (for me or my child) or if my best interest is served by such a consultation.
• I am over 18 years of age and have voluntarily chosen homeopathy care for myself/my child.
• I am aware that the outcome and duration of homeopathy care may vary by individual and cannot be guaranteed, and that the assigned practitioner offers no warranty or guarantee as to the outcome of the homeopathy care.
• I agree that I have a choice with regard to where I obtain the homeopathic remedies recommended.
• This Agreement shall be governed by the laws of HOHM Foundation’s incorporating State of Delaware and the venue of any action brought concerning the interpretation or enforcement of this Agreement shall be proper in the county the practitioner 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 or treat disease. All recommendations are for wellness and overall health building purposes.

As an educational institution, HHN is ethically required to recommend and abide by public health guidelines. If your symptoms change such that you need medical evaluation before continuing further homeopathy support, this will be clearly communicated to you.

I verify that I have read and understand the terms of service outlined above and hereby give my consent for care.

Research Consent*

I consent to have my anonymized clinical information from my case used for research purposes. I understand that my right to privacy will be protected. All potentially identifying personal information is removed in all HOHM research. I also understand that I have the right to withdraw consent to have my information used for research purposes at any time by contacting [email protected]. For any questions about the nature and scope of the research, you can contact [email protected].

Yes, I consent to have the anonymized clinical information from my case used for research purposes.

No, I do not consent to have the anonymized clinical information from my case used for research purposes.

Signature

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Regular Hours of Operation:

Monday – Friday 9:00 AM – 6:00 PM Eastern Time

If we have availability on the weekend, our volunteer admin and practitioners will do their best to contact you.

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Chronic Consult Practitioner Tiers

Contact Information

Health Information

Deposit

Agreement for Consultation

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