Your name
*
First Name
Last Name
Your preferred pronouns:
Your email
*
Your phone number
*
(###)
###
####
Preferred method of contact:
Other:
Partner/Support persons name (if applicable)
First Name
Last Name
Partner/ support persons preferred pronouns:
Tell me a little about what prompted you to reach out:
What services are you interested in?
If you menstruate, do you chart your cycle? If so, what methods do you currently use?
Are you actively trying to get pregnant? If so, how long have you been trying?
If you have had previous pregnancies, what were the outcomes? (vaginal birth, cesareans, VBAC, multiples, loss, etc.) Please include as many or as little details as you’d like.
Do you have any known medical conditions which may effect your menstrual cycle or fertility?
Where do you carry tension in your body? What do you find helpful for that?
What is your current stress level? In what ways do you deal with stress in your life? What helps you to feel calm and grounded?
In previously painful or emotionally intense situations (illness, injury, surgery) what have you found comforting?
Do you feel that you have a supportive community in the area? If not, what can I do to help you feel supported?
Please share anything else you would like me to know about you or any topics you would like to discuss
