Mold Toxicity Consultation Questionnare

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Age *

Are there any other members of your household who are sick (i.e., spouse, children, pets, other)? If so, please list below: *

I prefer: *

Phone sessions Zoom sessions that are audio only Zoom sessions that include video

Why do you suspect you have mold toxicity? *

Have you had your mycotoxin levels tested? *

Yes No

Please list your symptoms below: *

Approximately how long have you been sick? *

List all medications you are currently taking: *

List all supplements you are currently taking below (or email supplement list to [email protected]): *

List all professionally diagnosed medical conditions: *

Please list any doctors who are currently treating you for your symptoms: *

Would you like to understand more about EMF protection? *

Yes No

I agree to make my $100 donation for my mold toxicity consultation at the end of my session. *

Agree

Additional Comments: *

Confidentiality and Indemnification Clause: The advice and information provided through this ministry is offered by a certified holistic health counselor and certified member of the American Association of Drugless Practitioners (AADP) and not a state licensed counselor or medical professional. Any advice, suggestion, or recommendation provided during the mold toxicity consultation and through this ministry is based upon Stephanie Stanton's acquired knowledge and experience as a mold illness survivor and should not be considered professional legal, financial, medical, psychiatric, or technical advice. Therefore, if you have a significant legal, financial, medical, psychiatric, or technical need, please seek assistance from an independent licensed professional, accordingly. I acknowledge that any advice, suggestion, or recommendation made through this ministry will be acted upon by my own volition and free will. I take responsibility for all decisions and health related choices I make based on the counsel or advice I receive through this ministry. I further promise and agree to indemnify and release Holistic Christian Therapies, and Stephanie Stanton, of any and all liability arising from any known, unknown, or any unanticipated damages to myself, others, or property caused by the decisions and choices I make as a result of the counsel or advice I receive through this ministry. I am fully aware of, understand, and agree to all the terms and conditions of this release and indemnification provision, and that it is binding and enforceable by law.

I have read and agree to the clause above: *

Agree

Submit

If this is an emergency, please call:
SUICIDE HOTLINE: Dial 988
ABUSE HOTLINE: (800) 799-7233
ADDICTION HOTLINE: (800) 662-4357
SEXUAL ASSAULT: (800) 656-4673
MENTAL HEALTH: (800) 950-6264
SUPPORT FOR VICTIMS OF TRAFFICKING: (678) 336-2410

Stephanie Stanton, H.H.C.
Cell/Text: (201) 892-3959
Email: [email protected]
Located in South Florida and the Ozarks

Hours: Monday-Friday, 10 AM-6 PM EST
Zoom or phone sessions available

Mold Toxicity Questionnaire