Womb Light Intake Form

Womb Light Intake Form
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
How did you hear about this service?*
Have you ever had energy healing before?*
If yes, describe your experiences.
Trying to conceivePregnantPostpartum Mood and Anxiety DisorderPostpartum DepressionBaby BluesStressDepressionAnxietyImbalanced HormonesInsomniaBlockageImbalanced CharkasPast TraumaFearNegative Energies
How long have you been "trying" for or how long did it take you to conceive?
Have you ever had a positive result on a pregnancy test you have taken?
Do you have any children?
If so, how was your experience conceiving, carrying, birthing them?
What treatments/methods have you tried/completed for your problems?
Are you considering anything else?
Have you experienced loss?
Describe your current stress around this area of your life?
Tell me about your menstrual cycles since your first period.
What do you refer to as the higher power of this world if anything (Universe, Source, God, Angels, etc.)? So, I can use the proper term during our session.
Do you have any current rituals or routines in regard to your fertility?
CrystalsEssential OilsMeditationEFT/TappingHerbs
Would you be open to hearing ways those (question above) could help you in this journey?
How do you feel about the current state of your nutrition and activity level?
How do you feel about your current sexual health, sexual activity in your relationship and overall mindset about sex right now?
Tell me about anything else regarding your lifestyle, health, and wellness that you believe maybenefit this session.
Disclaimers: Womb Light is not a substitute for Medical Professionals or Medical Care. All information regarding your previous health history is optional and not required for you to share, but is very helpful. All information will be confidential according to HIPPA law. If you state you want or are going to hurt yourself or others I have to report it to the proper authories. If you state that a minor has gotten or will get hurt in anyway I have to report it to the proper authories.
Please verify that you are human*
Should be Empty: