First Consultation Form

Consultation Form

Anika Vanim is a holistic practitioner and sole propreitor of The Gypsy Mama Co. (llc) formed in southeastern Pennsylvania. We offer online and in-person birth & family support with real practitioners in real time, assisting individuals and families from conception to birth and beyond. The Gypsy Mama Co. and affiliates' support can include: phone or video consultations, birth planning, researching and compiling requested datas or provider lists, information regarding family planning/childcare/wellness, and references for non-emergency/non-medical care services such as individual and family advocates, doulas, nannies, yoga instruction, Reiki practitioners, family and event photographers, errands, pet or house sitting, cleaning services, and alike.

Filling out the form below allows our care providers to get to know you in whatever position you're experiencing life from. Whether you're just looking for information, rounding out your birth plan, collecting holistic references, or anticipating hiring a doula or nanny, we are so glad to meet you!

Name

FirstLast

Birth Date

MonthDayYear

Phone Number

Format: (000) 000-0000.

E-mail

example@example.com

Occupation

Are you currently:

What services are you looking for?

How can we assist you?

Health Information

Have you been experiencing any adverse health conditions?

This could be mental, emotional, or psychological ~ chronic, sudden, fleeting, or just concerns.

Are you experiencing any positive progressions to your health?

*ALWAYS WORTH DISCUSSING! :)

What kind of care model do you prefer from a practitioner? Are you willing to explain if/how this compares to your faith or beliefs?

How involved are you looking for your care support to be? Do you come from a supportive community?

How do you rate your stress levels in the last 6mo?

1

2

3

4

1 is Low, 4 is High

How do you rate the quality of your sleep in the last 6mo?

1

2

3

4

1 is Low, 4 is High

Best date to contact you:

Client Agreement:

The Gypsy Mama Co. & practitioners do not diagnose illness, disease, physical or mental disorders, prescribe medical treatment, pharmaceuticals, or attempt to cure ailments. The named party above, herein referred to as 'Client', acknowledges that holistic therapies are not substitutes for medical examination or diagnosis. It is recommended that clients consult a physician for medical services. Client must relay all health options and concerns to their primary care provider or a trusted medical professional. If experiencing pain or discomfort due to pre-existing pregnancy or health conditions, Client must seek medical assistance immediately. The Gypsy Mama Co. associates do not administer medical care. The Gypsy Mama Co. and associated care providers are not responsible for individual actions of the Client. Client is encouraged to disclose current medical conditions with practitioners sought within this consultation and update on any changes in health status. All information is held confidentially.

Compassionate, informed care for all: This is our commitment to non-discrimination.

By electronic signature below, client accepts the above agreement to book their consultation with The Gypsy Mama Co. and affiliates. We can't wait to assist you!

*The first consultation is free ~ appointment rate is $45.

*Clients in need are always welcome to send a message to thegypsymamco@gmail.com to discuss sliding scale fees!

Your Signature:

Submission Date:

Date