Holistic Menstrual Cycle Healing Pre-Consultation Form
Please share what you’ve been experiencing, noticing, and hoping to explore in relationship to your menstrual cycle. Your responses will help Melanie, owner of Embodiment Era, create a personalized 1:1 somatic/holistic menstrual cycle consultation for you to move forward in living in flow with your cyclical nature.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What is your preferred method of contact for our sessions?
*
Email ~ includes written advice, plans, feedback, and support
Text Message ~ same as email but feels more like chatting with a friend
Zoom calls ~ verbal advice, plans, listening, feedback, and support
Phone calls ~ same as zoom without the video
What symptoms or struggles do you currently experience related to your menstrual cycle?
*
Cramps
Mood changes irritability, or feeling more emotionally reactive
Irregular cycles
Heavy bleeding
Bloating
Fatigue
Difficulty becoming pregnant
Lighter, or missed periods
Anxiety or feeling unusually on edge
Sleep disturbances or difficulty staying asleep
Breast tenderness
Acne or sensitive skin
Headaches or changes in migraine patterns
Changes in libido
Hot flashes and night sweats
Vaginal dryness or discomfort during sex
Brain fog, difficulty concentrating, or feeling less mentally sharp
Joint and muscle aches
Changes in body composition
Feeling disconnected from my body
Feeling disconnected from my cycle
What’s the main occurrence happening in your body, cycle, or life that brought you here?
*
What feels true for you right now
*
Hormone imbalance
Nervous system dysregulation
Painful periods
Trying to conceive
Emotionally dysregulated
Struggling with PMS in my luteal phase
Have you had any recent changes in your health, lifestyle, stress, exercise, nutrition, or medications?
Do you believe you have the power to heal?
Are you on birth control?
No
Hormonal (pill/patch/ring)
IUD (hormonal)
IUD (copper)
Just got off
How familiar are you with your menstraul cycle and mind/body connection?
I know when I'm bleeding
I know there's four phases
I practice cycle syncing
I struggle with mind/body connection
I am learning mind/body connection
I experience my being as a whole
What are you hoping to understand, shift, or feel more connected to through our work together?
*
Are you open to holistic, somatic, quantum, and spiritual approaches to healing?
*
What price range feels comfortable for you right now?
*
>$50
$50-$100
$100-$300
Trade
Is there anything else you'd like me to know before your consultation? This is your space ~ share whatever feels relevant.
Submit
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