New Patient Intake Forms


In order to create an effective treatment plan as well as select the most appropriate homeopathic remedy, we would like to request that you supply our office with the information detailed below.

The Intake Form can be sent through email as an attached document to the office at:

Alternatively, it can be printed and mailed to our offices at:

Center for Homeopathy
220 Western Avenue
Brattleboro, Vermont 05301

In the case of children or persons otherwise incapable of writing themselves, the responsible person is requested to supply the information as best as possible.

We are aware that the amount of information requested is quite extensive. Please do not let it overwhelm or deter you, simply respond as best as possible and focus on what you consider the most relevant information pertaining to you. Again, please keep in mind that the more accurate and forthright the information, the more useful it will be to properly evaluate your case.