Intake Form - Online Course — EarthStar.Birthing

Please complete this form prior to your first session, and with enough time so I have your address to post you some rose tincture and / or any other herbs.

All information will be kept safe and confidential. All information will be viewed in a compassionate and non-judgemental capacity.

Please make payment of £80 deposit or full balance of £200 before the first session to:

Account Number: 75471809

Sort Code: 600238

Account Holder: EA Taylor

Reference: intuitiveonline

Any queries get in touch:

emily@earthstar-birthing.co.uk

School of Intuitive Herbalism - Online Course

Name

First Name

Last Name

Postal Address

Please tell us about any significant medical conditions and any medication you are on:

Do you have any allergies or any reason to believe you may be allergic to a plant:

Do you have any experiences of mental health challenges either past or present:

Are you pregnant or Breastfeeding:

Do you have a sensitivity to Alcohol (we may use tinctures in the sessions which contain alcohol. Most of the alcohol will evaporate when mixed with boiling water, but do let me know if you need to avoid alcohol completely, and I can accommodate.)

Yes

Please share briefly what your intention is for participating in this course, and a bit about your connection to nature and the plants

Is there a particular section of the course you would specifically like to go into detail with

Please tick if you are happy to be added to Emily's mailing list for other offerings

Yes