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Steam on Scene | Intake Form
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1
Your Name
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Please share how you wish to identify.
First Name
Last Name
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2
Join the GEM Space Mailing List!
Please share your email address.
example@example.com
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3
Site Address
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Please list the address where the "Steam on Scene" will take place.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Cote d'Ivoire
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Cuba
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Cyprus
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Laos
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Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
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Maldives
Mali
Malta
Marshall Islands
Martinique
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Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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4
This form helps determine if a steam is right for you, and if so which steam approach is best! That means that there are certain conditions in which a steam is
not
appropriate. Please select a response below and continue with the form if you understand.
*
This field is required.
Please Select
Yes, I understand.
No, I don't understand.
Please Select
Please Select
Yes, I understand.
No, I don't understand.
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5
This is my first time yoni steaming!
*
This field is required.
YES
NO
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6
Please Check All that Apply.
*
This field is required.
I am pregnant or may be pregnant.
I am spotting blood.
I spot/bleed between periods.
I am trying to become pregnant.
I am on my period.
None of these apply to me.
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7
Please Check All that Apply.
*
This field is required.
I am experiencing an itch or burn in my genital region.
I have had a tubal coagulation.
I have an STI right now. (bacteria, parasitic, viral, yeast infections)
I have had a uterine ablation procedure.
I am on hormonal birth control.
I am experiencing discomfort in my genital region.
None of these apply to me.
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8
Please Check All the Apply.
*
This field is required.
I experience night sweats.
I experience hot flashes.
I have "two periods a month".
I have short menstrual cycles. (27 days or less)
My period is absent.
I experience vaginal dryness.
I experience vaginal dampness.
I have irregular vaginal discharge.
None of these apply to me.
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9
Do you have any allergies?
*
This field is required.
Please also indicate if you have any allergies to herbs!
Type in your allergies or write "No Allergies" if you have no allergies.
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10
Water steam warms up your body's circulation. This could impact your blood flow, including for those with blood-related health conditions. Please understand that completion of this form and willingness to sit for your steam is voluntary and at your discretion. Your Steam Facilitator is not a medical professional and a GEM steam is self-care recreation. Please select "Yes" if you understand.
*
This field is required.
YES
NO
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11
In the event of an emergency, please list an emergency contact.
*
This field is required.
Include 1) Name 2) Full Phone Number 3) Relationship
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12
Please understand that completion of this form does not mean you will be approved a suitable client for a GEM Steam. Your responses help determine fitness for a steam, length of steam, temperature of steam, and herbs selected. Please select "Yes" if you understand.
YES
NO
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13
Thank you for completing your GEM Steam intake form, we will follow up soon. Please share anything else you may like to add. Then Click Submit!
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