THE PROTOCOL FOR HAIR ANALYSIS, DIAGNOSIS, AND PRESCRIBING OF SUPPLEMENTS
OVERVIEW - How It Works:
1. You print out this entire form and complete all parts of the printout, including the "Initial Exam Questionnaire."
2. You send that printout along with a hair sample (collected per directions below) and either a money order, a cashier's check or your credit card information.
3. Upon receipt of that information, I will contact you to schedule an appointment to conduct a diagnostic interview.
4. Following that initial interview, I will turn in to the lab the form, the hair sample, and their fees.
5. After receiving the report from the lab (which generally takes 7-10 days), I will contact the doctor and set up a 3-way call at a time that works best with everyone's schedule. (Please Note: I am blocking out one hour of the time that I reserve for my other clients, and the doctor will be doing the same; therefore, if a client misses the phone session without giving us a 24-hour notice so we can schedule someone else into that time slot, the client will have to reschedule and pay for another session since we could have booked a client during that time.)
6. During the three-way conference, the doctor will explain the results to the client and will prescribe any supplements indicated by the exam as needed. The doctor will also determine the proper dosage information. We will then provide you with the telephone number of the pharmacy. (When you call, ask for Michelle. You may provide your mailing address and credit card number and she will ship your order. You may want to pay the additional fee to expedite the shipment.)
Sincerely,
Marie Lachney LPC, LMFT,
New Pathways Counseling Center
COLLECTING THE HAIR SAMPLE
The client should clip (or have a friend clip) about thirty strands of hair - very close to the scalp, preferably close to the nape of the neck - and send that in a separate envelope along with the package that you'll be mailing.
ABOUT THE FEES
We want you to know exactly what you will be receiving for the payment you submit. For the fee you submit, Marie Lachney will:
- provide protocol sheets via this website
- process the forms on receipt
- arrange and conducting a diagnostic interview
- create your individual file
- determine specific additional test items to be checked on the hair analysis
- pay for the telephone call for that interview
- deliver all forms to the lab
- pay the lab for the basic analysis + the analysis of up to five additional specific diagnostic areas as requested by the psychotherapist ($180.00)
- collect all forms and results from the lab
- fax results to the naturopathic physician
- fax results to the client
- call the doctor to schedule the three-way interview
- call the client to schedule the three-way interview
- pay for the three-way call
- pay the doctor ($75 minimum)
- participate in the three-way call, for up to an hour
- create the case notes
- provide a written protocol to the client
- make recommendations for other helpful, indicated treatments
- provide a specific body-type food plan via this website
- provide contact information regarding the pharmacy
- confirm prescribed supplements with the pharmacy
- track your schedule and inform you in advance of the dates for your 90-180-270 day follow-ups and progress checks
FEES FOR OPTIONAL SERVICES
- $15 per e-mail (e-mails to coordinate times for phone conferences are not charged)
- $70 per phone conference up to 50 minutes if therapy is also indicated or if further discussion is desired by the client
THE NEXT STEP
(After you have printed a copy of this website page, please complete on your hard copy the following questionnaire. You will mail it to our office.)
INITIAL EXAM
NAME:____________________ DOB:________ HEIGHT____WEIGHT______
STREETADDRESS:__________________________________________________
CITY:________________________ STATE:________________ ZIP _________
HOME PHONE_________________________ CELL PHONE:__________
EMAIL: _______________________________
FAX #________________
(Needed to fax test results)
PRESENT COMPLAINTS: _______________________________________________________________________________
REMARKS:____________________________________________________________________________________________
1. Do you have headaches? ________________________________________________________________________________
2. Do your eyes ever bother you, if so how? ___________________________________________________________________
3. Do you ever have sinus trouble? __________________________________________________________________________
4. Do you get colds easily or frequently? _____________________________________________________________________
5. How is your appetite? __________________________________________________________________________________
6. Do you have many dental cavities? Yes No How many natural teeth have you lost? __________________________
7. Are your gums bleeding or sore? _________________________________________________________________________
8. Do you have any hearing problems? _______________________________________________________________________
9. Do you have earaches? _________________________________________________________________________________
10. How is your sleep? ___________________________________________________________________________________
11. How is your energy level? _____________________________________________________________________________
12. Are you aware of your heart action? Yes No Does it bother you in any way? _______________________________
13. Do you have any history of high or low blood pressure? ______________________________________________________
14. List past aliments: ____________________________________________________________________________________
15. Have you had any surgery for removal of organs? ___________________________________________________________
16. Have you ever had diabetes? ____________________________________________________________________________
17. Do you have asthma? Yes No Do you have bronchitis? Yes No
18. Do you have pleurisy? Yes No Do you have pneumonia? Yes No
19. Do you have stomach distress? Yes No Before of after eating? _______________________________________________
20. Do any foods seem to cause you trouble? __________________________________________________________________
21. Do you have any internal pains? Yes No If so where? ____________________________________________________
22. Do you have any stiffness, soreness or pain? Yes No If so, where? ___________________________________________
23. Do you have constipation? __________________________________Do you have diarrhea? _________________________
24. Do you have a history of skin trouble? ____________________________________________________________________
25. Have you ever had any problems with anemia? _____________________________________________________________
26. Men- Have you ever had any prostate trouble? _____________________________________________________________
27. Women- Have you ever had any female problems? __________________________________________________________
28. Does it burn when you urinate? _____________________ Do you have to go frequently? ___________________________
29. Do you have to get up during the night? ___________________________________________________________________
30. Do you have any history of kidney trouble? ________________________________________________________________
31. Have you ever had kidney stones? _______________________________________________________________________
32. Do you have any emotional problems? ____________________________________________________________________
33. Do your ankles or legs swell? ___________________________________________________________________________
34. Have you ever had x-ray therapy? _______________________________________________________________________
35. Have you ever had any other type of therapy? ______________________________________________________________
36. Have you ever had a Fluoroscopic exam? Yes No How recently? ________________________________________
37. Smoking- Do you smoke? Yes No How many cigarettes per day? _____________________________________________
38. Alcohol- Do you drink? Yes No Occasionally? _________________________ Daily? __________________________
39. Drugs- Specify which ones___________________________________ How often taken? ___________________________
Include any tranquilizers and sleeping pills ________________________________________________________________
40. Do you use deodorants? Yes No Do you use anti-perspirants? Yes No
41. Are any of your cooking utensils aluminum? Yes No Are any coated with Teflon? Yes No
42. Do you have a microwave oven? Yes No
43. Do you own a color TV? Yes No How many? _______ How many hours per week do you watch? __________________
At what distance from the TV? __________________________________________________________________________
44. Do you use pesticides? Yes No State which and how often used: _____________________________________________
45. Are you taking any vitamins? Yes No Please list: __________________________________________________________
Do you take any patent remedies? Yes No Please list: ____________________________________________________
46. Do you take any laxatives? Yes No Please list:_____________________________________________________________
47. What is your occupation? ______________________________________________________________________________
48. Have you followed a particular diet recently? Yes No Please give details:_______________________________________
Please use this space for any additional information that you would like to include
Please include your e-mail address if available:_______________________________
PAYMENT
You may send a cashier's check or money order made payable to Marie Lachney for $375.00 or you may complete the credit card information below:
If using a credit card, please complete the following:
Please print your name as it appears on your card:
_______________________________________
Type Card: (Please circle one): VISA or MasterCard
Credit Card Number:
__________ ____________ ___________ _____________
Expiration Date Month:________
Expiration Date Year:________
Signature and date are required. My signature below indicates that I authorize Marie Lachney to charge my credit card account with a charge of $375.00 for services to be rendered:
Signature:____________________________________Date:_______________
REGARDING INSURANCE
If you have insurance available, we may be able to bill your company for the therapist's services and save you some money; therefore, if coverage is currently in force, send a copy of the front and the back of your insurance card with the above items. Our office manager will contact the company and notify you if benefits are available.
SUBMITTING YOUR PACKAGE
Please complete this final checklist:
_____The money order, cashier's check or completed credit card information
_____The hair sample, cut close to the scalp/nape of the neck
_____The questionnaire below entitled "Initial Exam"
_____Include the best time that you can be reached by phone
_____Include telephone number and fax number
_____Include e-mail, if available
_____Insurance Information** see below**
The entire package should be mailed to:
Marie Lachney
2012 Andrews Street
Alexandria, LA 71301
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