Mothers Medicine Intake Form

If you are an existing client please do NOT fill out this form again – you can access the client resource platform and update your details here

If you are new to this platform and have been directed here by a Practitioner or trusted friend – Welcome.

Before commencing this intake form, please ensure you read and understand our Privacy Policy and Terms of Servic Submitting the form below is an agreement of these terms.

  • The below questionnaire has been designed to help determine the most appropriate plant medicine protocol for you. This is an essential requirement for an initial consultation to assist in providing the correct on-going support for your wellness goals.
  • Ensure you have at least 15 minutes to complete the form in one sitting, or have essential information handy elsewhere on your computer for you to copy and paste as needed as you will not be able to save the form and come back to it.
  • If you are completing this form on behalf of a child, another person or an animal, please ensure your contact details are noted in the "Carers" section and only complete questions that apply to the relevant situation.
  • Level 1 Consultation Fee - $150 – payable upon submission of form. This includes consultation, recommendations, access to this resource platform including Practitioner only formulas, and support for 1 month.
    Your practitioner can discuss ongoing support and further consultations if needed, based on your personal circumstances. If you are experiencing financial difficulties, please contact us on the email below.
  • After your form is submitted you will receive a welcome email that contains important information about your consultation and our Frequently Asked Questions (FAQ's) that may be helpful for you and your support team.

 If you do not have a preferred Practitioner or Wellness Clinic, you will be connected with the most appropriate Certified Natural Lore Practitioner to suit your circumstances.

  • The email and password you select for your account will be your access to on-line product ordering and support resources.
    Please note that your application will be approved at the time of consultation which will then grant you full access to the site and NOT before

If you have any questions or issues with this form please contact This email address is being protected from spambots. You need JavaScript enabled to view it.

Existing user? Please login

New User? Please register

Account Information

Medical History

Please tick your issue from the following conditions listed below .. If you have something other to what’s listed, please write a detailed description of your condition below, including all relevant information. Please include any recent reports of tests done when you send this form back or prior to a consultation . PLEASE BE VERY SPECIFIC WITH ANY OFFICIAL DIAGNOSIS:
Indicate your CURRENT levels of the below issues with a rating of 1 - 10 (1 being lowest and 10 being highest). Use how you would normally feel as the reference point:

Personal History and Situation

We endeavour to be as thorough and supportive to your individual needs as possible. The following are a series of questions which help us to determine where you are in relation to your own well-being and healing. Your honesty in answering the questions are of benefit to YOU by assisting the practitioners to determine the most advantageous holistic approach for you– so please sit quietly with each question before answering. Your answers are private and confidential;
I have read, reviewed and understand and agree to the statement of the Privacy Policy and Data Collection for healthcare services in this office as outlined by the above. Our Office has attempted to provide each patient with a statement of privacy policies. By signing up to this subscription plan and agreeing to the Privacy Policy you agree to this web site storing your information.
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Call: 0415 207 887