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Holistic Detox
client intake form

Personal Information

Human Design Type & Autority

I'd like to know my Human Design type and inner authority. Understanding your Human Design type can provide insights into yourself and assist you in handling detox in your own unique way.

Knowing your degisg can give you extra clues and direction in dealing with the health crisis

Date and time of birth
Year
Month
Day
Time
:

Health History

Indications for Detoxification

General Detox Indications. Please choose anything that is applicable to you. Please make sure to consult with a Healthcare professional directly if you have any health issues (see Disclaimer).

Liver Flush

Liver Flush is an optional procedure that you can undergo during the physical body detox. These symptoms may indicate Liver congestion. Please mark what is applicable to you.

Contraindications to Detox

Please choose anything that is applicable to you

How are you managing it? Are you being monitored by a medical professional?

Please indicate the year when you were first diagnosed or when the symptoms first appeared.

For example: I would like to gain mental clarity and fregain a healthy eating habbit, not experince constipation and feel more energetic in the morning.

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