Burch Bear Holistic Care — 1-on-1 Consult Intake

1-on-1 · 90-Minute Consult

Client Intake Form

The more you share, the more personalized your game plan will be. This walks through your story, your symptoms, your environment, and your goals so we arrive ready to build your path — not a generic protocol.

Takes about 15–20 minutes · Please complete before your call

You're not crazy, and your body isn't broken — it's overloaded.

Everything you tell us is kept private and used only to prepare for your consult and customize your plan. Be as honest and detailed as you can — there are no wrong answers here.

Section 01

Your details

So we know who we're talking to and how to reach you.

Section 02

Why you're here

In your own words — this is the most important part. Don't worry about medical terms.

The lens we'll use

Toxicities
What's coming in
+
Deficiencies
What's missing
=
Dis-ease
The symptoms

The next sections map your symptoms, your drainage, and your exposures to this equation — so your plan addresses the root, in the right order.

Section 03

Symptom inventory

Check anything you experience regularly. This builds a picture across your whole body — many of these are connected.

Energy & fatigue
Brain & nervous system
Mood & sleep
Digestion & gut
Sinus & respiratory
Skin, muscles & joints
Immune, hormonal & sensitivities

Section 04

Drainage & elimination

Before the body releases anything, the exits have to be open. These answers tell us where to start.

Section 05

Mold & environmental exposure

Where you live and what you've been exposed to is often the missing piece. Think back across all your homes and workplaces.

If you have results, you can email PDFs to us before the call.

Section 06

Medical & health history

This helps us plan safely and avoid anything that doesn't fit your body.

Section 07

Medications & supplements

Everything you take right now — this is essential for timing and safety.

Section 08

Diet, hydration & lifestyle

A quick picture of your daily inputs and stressors.

Section 09

Detox experience & readiness

This helps us pace your plan to your body and your real life.

Section 10

Anything else

The floor is yours.

Section 11

Consent & acknowledgment

Please read and acknowledge before submitting.

  • Burch Bear Holistic Care provides holistic education, wellness coaching, and non-toxic product guidance. This consult is not medical care and is not a substitute for diagnosis or treatment by a licensed physician.
  • Nothing shared here is intended to diagnose, treat, cure, or prevent any disease. I will consult my physician before making changes — especially if pregnant, nursing, or taking medications.
  • I confirm the information I've provided is accurate and complete to the best of my knowledge.
  • I understand my information is kept confidential and used only to prepare for and personalize my consult.

Once you submit, we'll review everything before your call and arrive ready to build your customized game plan. See you soon.

Burch Bear Holistic Care | BurchBear.com | Scottsdale, AZ 85258