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Mountain Woman Medicine Consultation Questionnaire
Informed Consent & Full Disclosure for Holistic Consulting Services

This is designed to clarify the relationship between MWM & YOU, to help each other know what can be expected of the other and to help avoid misunderstanding and miscommunication. To help clarify what I can and can't help you with.

I’m not a doctor, nor a licensed medical provider. If you need these services, please do consult with a trained medical professional. If there is a problem, once you know what it is, then you can gather information and make an informed decision on how you want to go about handling the problem. Many people are choosing to work with natural products, some in dietary and nutrition alone, some wish to include energetic adjustments and lifestyle changes. All of these things are using more of a holistic, whole body approach to treating their health concern. There is this wonderful growing interest of individuals that wish to take greater responsibility for their own health care and general well-being. This is what I wish to support.

My work as a Holistic Resource is about empowering people to make wise self-care choices from a place of being well informed. I honor each person’s choice of choosing to embrace holistic health and work to assist that desire to work with alternative methods prior or in conjunction with the offerings of the medical establishment.

I am a researcher, educator and herbal practitioner. My goal is to educate people who come to me, provide resources, and encourage individuals to embrace responsibility for their own health. To encourage them to ask questions, to understand their own bodies and their own cycles, and to begin to identify what exists around them that might help them meet their goal.

By filling out this form and working with me, you acknowledge my limitations, and agree to take responsibility for your own health care choices, assuming the risk involved in any of those choices that you make. My goal is to educate you as best as I am able to, please use that information responsibly.

Just because it’s a natural or herbal product doesn't mean it is safe, or without risk. There is also no guarantee that herbal or vitamin supplementation will produce the desired effects. Please make all your health choices educated conscious ones.

How I can help you:
- I can offer in-depth consultations on Holistic health and offer strategies where needed.
- I can look at data/labs you provide and offer a holistic interpretation.
- I can give an opinion, make an educated calculation or give you a intuitive response/answer. - I can provide consultation to aid YOU in making educated decisions about achieving YOUR
personal goals for health and wellness.
- I can tell you what I might do if this was my body.
- I can discuss herbal formulas and preparations.
- I can assist you in understanding your own energetic state and ways to work with it yourself.
What I can’t help with:
- I can’t promise you any remedy will accomplish what you are hoping to do. - I can’t diagnose a medical condition

What is expected from You:
- Honesty
-When providing a history of the issue/s in question, full disclosure, including past medical/surgical history, medication list, allergies and healthcare practitioners that you are currently working with are needed.
- An earnest attempt and sincere commitment in meeting YOUR personal health goals. .
- Personal Research. Don’t take my word for it, read and educate yourself, verify and cross
reference.
- To take care of yourself. To look out for yourself. To protect yourself. Respect yourself. - To make decisions based on good information.
- Not to make fear based decisions.
- To provide information about any medical conditions you may have.

What You Can Expect From Me:
- Honesty
- I am knowledgeable in Anatomy & Physiology, Microbiology, general nursing & paramedic practice, many
medical conditions and treatments, women’s health and herbs, first aid treatments, local plant Materia Medica, herbal medicine making & energetic balancing. - I’m a collector of information and an educator.
- That I will do my best to answer your questions and concerns.
- That I will admit that I don’t know the answer if that is the case.
- A sincere desire to help and educate.

Fees Known as “Exchange” on The Mountain:
-Consults are $150/hr or pay what you can.
-Specific remedies may be acquired through me as well. Pricing discussed during consult, typically tinctures range around $20 per oz, Nemeton’s Wellness Clinic can sometimes offer scholarships towards the acquiring of Herbal Supplements or Build Your Own Apothecary kits. Feel free to inquire.

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Email *
Full Name & Desired pronouns *
Date, Time(am/pm) & City & State of Birth (This is used to factor InnerCartography Mapping) *
What is your Main reason for this Session? *
What kinds of Health Providers are you currently seeing? *
What is your Health History? (Give brief layout) *
What, if any, medications, supplements or vitamins do you take on a daily basis? *
What Allergies or Adverse Reactions do you have or have experienced with medications, herbs or supplements? *
Constitution: Select 1, 2 or 3 of the following (we are a mix) *
Required
Constitution: What Tastes do you like (Check all that apply) *
Required
Constitution: What is your favorite Season & Why? *
Emotional (Choose all that apply) *
Required
What does an average daily diet look like for you? Is it different right now? *
Thank you!
Your Responses will be logged and an appointment will be set up & confirmed with you! Lotsa Love from The Mountain!
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