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Contact Form

Contact Form For All Services

For Israeli Residents ONLY

Read About Fees For Programs and Services BEFORE Completing This Form

Sending this form doesn't require payment. You will be sent the Questionnaire Analysis which you'll need to pay 150₪ in order to start the work. Payment can be done online. 


REQUEST A CONSULTATION OR SERVICES

First and Last Name:

Phone number(s):

When's the best time to reach you:

Email (please double check):

Name of Person for Care (also for Tefilla): ____ bat _____

Age of Person for Care:

Address:

CURRENT HEALTH ISSUE

Select the program of your choice. Choose only one:

  1. Chronic Care program
  2. Complex Chronic Care (more than 2 health issues)
  3. Fertility/Pregnancy Program
  4. ADHD/ASD Program
  5. Homeopathic Detox Program
  6. Spiritual Homeopathy Program
The Acute Care Program is addressed with a different questionnaire. 
Read the Terms and Conditions for the pricing and other details. 

What is the MAIN ISSUE or DIAGNOSIS that are you are seeking homeopathic care for?

Please select the ONE (1) Main Health Concern that applies to the person the you are seeking care for.

If there is a medical diagnosis made, pick the MAIN ONE diagnosis that matches the main issue.

You will explain more details in the comments section below.

  • Acne
  • Allergic rhinitis
  • Allergies
  • Ankylosing spondylitis
  • Anorexia nervosa
  • Anxiety
  • Anxiety disorders in children
  • Appendicitis
  • Arthritis
  • Asthma
  • Atopic Eczema
  • Attention deficit hyperactivity disorder (ADHD)
  • Autistic spectrum disorder (ASD)
  • Bipolar disorder
  • Blood poisoning (sepsis)
  • Bronchitis
  • BulimiaMe
  • Cerebral palsy
  • Chest infection
  • Chest pain
  • Chickenpox 
  • Chronic fatigue syndrome
  • Chronic kidney disease
  • Chronic pain
  • Conjunctivitis
  • Constipation
  • Corona Virus (COVID)
  • Crohn's Disease
  • Cystitis
  • Dental Abscess
  • Depression
  • Diarrhea
  • Dizziness
  • Down Syndrom
  • Functional Neurological Disorder
  • Gallstones
  • Ganglion Cyst
  • Gastro-oesophageal reflux disease (GORD)
  • Gum disease
  • Haemorrhoids (piles)
  • Hay Fever
  • Headaches
  • Hiatus Hernia
  • Impetigo
  • Indigestion
  • Irritable Bowel Syndrom
  • Itching
  • Kidney Stones
  • Laryngitis
  • Measles
  • Menopause Issues
  • Otitis Media
  • Miscarriages
  • Mouth Ulcer
  • Migraines
  • Multiple Sclerosis (MS)
  • Obsessive Compulsive Disorder (OCD)
  • Ovarian Cyst
  • Post-traumatic stress disorder (PTSD)
  • Post-Natal Depression
  • Psoriasis
  • Raynaud's phenomenon
  • Shortness of Breath
  • Stress, anxiety and low mood
  • Any type of cancer
  • Tonsillitis
  • Toothache
  • Urinary Tract Infection (UTI)

How long has the main issue been a health condition?

  • 1-3 months
  • 3-6 months
  • 6-12 months
  • 1-3 years
  • 3-5 years
  • 10 years or more


Name each current or suspected diagnosis, in chronological order with the year it started after each.  
List any active medial diagnosis within the last 5 years.



Number of Total Diagnoses (CURRENT): 

COMMENTS: Please provided us with more general details on the nature of your inquiry.

How did you find out about us?

Have you ever used homeopathy before or worked with a professional Homeopath before?

Comments

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