Request for Referral

Waiting List Info

This is the referral form for International Homeopaths 4 Autism. Referrals are carried out by Wren Lloyd

Your name [for contact]

Your email address

Contact phone number + country code

Timezone of person consulting.

Facebook Profile URL (for easy contact)

ABOUT THE PATIENT [Fill a separate form for each patient you'd like to apply for]

Age & sex of person needing treatment

Diagnoses [if any] of person requiring treatment

Date of patients last high fever [39C or 103F or above].

What recurrent infections has the patient suffered?

List the issues you want treatment for, with the most important at top. [Also, show severity out of 10]. This information is very useful in helping me meet your needs.

Make a Wishlist of gains you'd like to see from treatment [start with the most important]. This info is very useful in helping me understand your needs.

Any relevant test results you wish to send [ie, ATEC, OATS, HTMA].

Add file

Please upload a file

PRIVACY & DATA HANDLING

I am happy for International Homeopaths For Autism to hold my private information securely and to contact me via email.

Your information will be encrypted.

Request for Referral

Waiting List Info

ABOUT THE PATIENT [Fill a separate form for each patient you'd like to apply for]

PRIVACY & DATA HANDLING

Waiting List Info

International Homeopaths for Autism

Led by Wren Lloyd, with specialisms in ASD, Autoimmunity, Tooth Health, & Detox.