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Client Support Form

theportal.life is a private membership collective which shares from the depth of our experience and care. You are welcome to join.

Institute Botanica

Client Support Form

If you are an existing client please do NOT fill out this form again – PLEASE LOGIN first at the top of this page, you can access the client resource platform and update your profile details here.

If you are new to this platform and have been directed here by a Practitioner or trusted friend – Welcome.

Before commencing this intake form, please ensure you read and understand our Privacy Policy and Terms of Service and our Association of Agreements
Submitting the form below is an agreement of these terms.

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  • The below questionnaire has been designed to help determine the most appropriate plant medicine protocol for you. This is an essential requirement for an initial consultation to assist in providing the correct on-going support for your wellness goals.
  • Ensure you have at least 15 minutes to complete the form in one sitting, or have essential information handy elsewhere on your computer for you to copy and paste as needed as you will not be able to save the form and come back to it.
  • If you are completing this form on behalf of a child, another person or an animal, please ensure your contact details are noted in the "Carers" section and only complete questions that apply to the relevant situation.
  • Level 1 Consultation Fee - $150 – payable upon submission of form. This includes consultation, recommendations, access to this resource platform including Practitioner only formulas, and support for 1 month.
    Your practitioner can discuss ongoing support and further consultations if needed, based on your personal circumstances. If you are experiencing financial difficulties, please contact us on the email below.
  • After your form is submitted you will receive a welcome email that contains important information about your consultation and our Frequently Asked Questions (FAQ's) that may be helpful for you and your support team.

If you do not have a preferred Practitioner or Wellness Clinic, you will be connected with the most appropriate Certified Natural Lore Practitioner to suit your circumstances.

  • The email and password you select for your account will be your access to on-line product ordering and support resources.
    Please note that your application will be approved at the time of consultation which will then grant you full access to the site and NOT before.

If you have any questions or issues with this form please contact support@theportal.life

    Medical History


    You may select multiple categories. When selected, please provide details below.

    Neurodevelopmental conditions

    Developmental or genetic conditions

    Mental health conditions

    Neurological conditions

    Cognitive or neurodegenerative conditions

    Autoimmune or inflammatory conditions

    Chronic pain or musculoskeletal conditions

    Cardiovascular or autonomic conditions

    Respiratory conditions

    Digestive or gut conditions

    Endocrine, hormonal or reproductive health

    Cancer

    Vision or eye conditions

    Vaccine injury

    Quality of life or palliative care support

    Other diagnosis or health focus

    Indicate your CURRENT levels of the below issues with a rating of 1 - 10 (1 being lowest and 10 being highest). Use how you would normally feel as the reference point:






    Payment Information


    $


    I agree
    Privacy Policy

    I have read, reviewed and understand and agree to the statement of the Privacy Policy and Data Collection for healthcare services in this office as outlined by the above. Our Office has attempted to provide each patient with a statement of privacy policies. By signing up to this subscription plan and agreeing to the Privacy Policy you agree to this web site storing your information.

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