Client Application

Application to Become a Client of

Rocky Mountain Holistic Herbalism, LLC
“Hunger is cured by food, ignorance by study;
you're looking for a good herbalist, I'm looking for a good client.”
All fields are required. Incomplete applications will not be accepted.
NOTE: If you need to leave this form before you're finished, it should save your progress, as long as you use the same browser on the same computer when you come back to it.
Name*

First NameLast Name
I prefer to be called*
E-mail*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Where did you hear about RMHH?*
Whose idea was it for you to seek help with us?*
Why do you want to work with an herbalist?*
Are you willing to change whatever you might need to change in order to get well (e.g., habits, living situation, job, diet, thoughts, etc.)?*

YesNo
Do you have the resources to pay for your sessions?*
Have you ever been diagnosed with any psychological disorder? If yes, which one?*
Are you willing to take 100% responsibility for your health and where you want it to go – NO whining, complaining about the healing program, excuses for not doing your homework, allowing other things to come between you and your healing program, etc.?*

YesNo
For which conditions are you seeking help?*
What other treatments are you currently using or do you plan to use (ALL of them)?*
Are you currently taking any prescription medications? If so, which ones?
Are you currently pregnant?*
Are you applying on behalf of a child? If so how old is the child?*
Do you currently have cancer?*
What does “Healing” mean to you?*
Why should I take you on as a client?*
Signature*

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Date*

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Application to Become a Client of