Womb Alchemy Consultation
First and foremost, thank you for seeking interest in my 'Womb Alchemy' services! The goal of our 30 min consultation is for me to understand your womb vision, whether you are seeking advice on conscious fertility, doula services, intimacy/ sex, or yoni steaming.This is an opportunity for us to connect, get to know each other and address any of your questions.This is your time to pick my brain and see if I am the right partner for your journey & find out how my teachings will benefit you.Everyone deserves a peaceful experience, and I want to make sure we get you that!
Service You are Inquiring About:
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Abortion Doula
Miscarriage Doula
Prenatal, Pregnancy + Postpartum Support
Conscious Conception
Tantra + Sexual Intimacy
Womb Healing + Reiki
Appointment
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Check All That Apply:
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I am reconnecting with my inner, youthful woman.
I am in monthly or daily pain from my periods or digestion.
I want to get off of hormonal birth control.
I am preparing for pregnancy.
I am currently pregnant.
I am feeling disconnected from myself.
I am struggling with anxiety, depression or bipolar emotions.
I want to learn about some herbs for women's health and fertility.
I want to learn more about how to eat for my body type.
I am interested in traditional techniques for taking care of my womb.
Name
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First Name
Last Name
Email
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example@example.com
Phone Number
Please enter a valid phone number.
Estimated Due Date (if expecting)
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Month
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Day
Year
Date
Birth Partners Name (if expecting)
Planned Method of Delivery
Hospital- Medicated
Hospital- Natural
Homebirth or Birth Center
Unassisted + Free Birth
Provider
OB
Midwife
Unassisted + Free Birth, No Provider.
Are you currently experiencing any specific health or other concerns? Any and all of your information, and anything you share will be kept confidential.
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Explain any complications you have had with this pregnancy or any restrictions your caregiver has given you. (if expecting)
If you are not currently expecting, have you been pregnant before? If so, how did it go?
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Have you given birth before?
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Yes. Vaginally.
Yes. Cesarean.
Yes. VBAC.
No.
Do you have a history of miscarriage or infant loss?
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Yes. Miscarriage.
Yes. Infant loss.
Yes. Both.
No.
If you are menstruating, do you have any of these symptoms associated with your menstrual cycles?
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Painful Cramps
PMS
Heavy Bleeding + Clotting
Multiple Cycles Per Month
Short Cycles (Shorter Than 27 Days)
Longer Cycles ( Over 35 Days)
Absent or Incredibly Short Cycles, Basically Spotting.
Back or Leg Pain
Nausea or Vomiting
I am pregnant and not menstruating.
I do NOT have any of these symptoms.
What would you like to gain out of this consultation?
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Signature
Date
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Month
-
Day
Year
Date
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