For children 18 years of age and under · Confidential
1 Child's Basic Information
2 Reason for Visit
3 Behavior & Temperament
4 Pregnancy, Birth & Early Development
5 Body Systems — Check Any Areas of Concern
6 Timeline of Major & Traumatic Events
Please provide a brief summary of any major life-altering events or traumatic incidents. Begin with the most recent event and work backward. We will explore these in greater depth during the consultation.
Date / Age / Period
Event Description
7 Consent, Authorization & Parental Signatures
By signing below, each parent or legal guardian certifies that:
The information provided in this form is accurate and complete to the best of their knowledge.
They authorize Suzanne Arkoosh, CCH, of The Butterfly's House to provide homeopathic consultation services for the child named herein.
They understand that homeopathy is a form of complementary wellness support and does not constitute the diagnosis, treatment, or cure of any medical condition.
They understand that all information shared is held in strict confidence and used solely for the purpose of homeopathic consultation.
They acknowledge that The Butterfly's House operates as a private membership association, and that membership is a prerequisite for services.
Parent / Guardian 1 (Required)
I have read, understood, and agree to the consent statement above.
Type your name above to generate your signature
Parent / Guardian 2
I have read, understood, and agree to the consent statement above.
Type your name above to generate your signature
Thank you for taking the time to complete this form. Your responses help us provide the most individualized and effective care for your child.