Date
*
MM
DD
YYYY
Name
*
First Name
Last Name
Gender Preference
*
Female
Male
Non-Binary
Prefer to Not Disclose
Occupation
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Phone
*
(###)
###
####
What is your preferred method of contact?
Email
Text
Email or Text
Do you have any children?
*
If yes, please share how your children came to you.
(select all that apply)
Have you ever been pregnant?
*
Yes, I have been pregnant
Yes, I am currently pregnant
No, I am trying to get pregnant
No, I am not trying to get pregnant
If yes, please share your experience(s) with pregnancy.
(select all that apply)
If yes, please share your experience(s) with labor and delivery.
(select all that apply)
Have you had any hospitalizations or significant injuries?
*
If yes, please list below.
Are you currently being treated for any medical issues?
If yes, please list what type(s) of practitioner(s) are treating what concern(s).
What forms of mind and/or body work have you experienced?
(select all that apply)
Do you pray or meditate on a regular bases?
*
Do you exercise on a regular basis?
*
If yes, what activities do you participate in?
(select all that apply)
How would you describe the way you eat most of the time?
*
(select all that apply)
If other, please describe.
What self-care practices do you currently have in place?
*
What motivated you to schedule a session?
*
What are you hoping will come out of our time together?
*
Do you have any topical or internal allergies?
*
If yes, please list below.
What modalities are you open to participating in at this time?
Do you have any sensitivities to certain sounds, smells, sights, tastes, or areas of touch?
*
If yes, please list below.
Do you have any personal or religious beliefs that you would like to be respected?
If yes, please explain how I can honor you in your beliefs.
Emergency Contact
*
First Name
Last Name
(###)
###
####