Intake Form - General — EarthStar.Birthing

Earthstar Birthing - Intake Form

Name

First Name

Last Name

Date of Birth

Address

Phone Number

Next of Kin (emergency contact details)

Current Medical Conditions / Diagnosis:

Current medications that you are taking - please include supplements, birth control, and herbs:

Do you have any allergies or any reason to believe you may have an allergic response to any plant?

Have you recently had any serious medical events that have required hospitalisation surgery, or aggressive drug treatment?

Are you pregnant or breast feeding?

Do you have a high level of (habitual) recreational drug use (including alcohol)? Do you have a history that includes exposure / high use of psychedelic substances?

Do you have (or does anyone in your close family) have experience of serious mental health challenges?

Please give details of any major childhood illness and or trauma that you feel may be relevant:

Any additional information?

Would you like to work in person or online

In Person

Online

What attracts to you explore working with plants in this way?

What are the themes, questions or areas of your life that you would like to explore in the sessions. This may change or evolve, but a brief outline helps sow the ground from which we can work together

How would you describe your connection to nature?

Do you have experience with holistic healing or working with healing as a process?

Sessions include gentle bodywork as well as meeting with a plant, please let me know if you have any injuries or other reason why it may be painful to receive bodywork

It is important that you fill out this form prior to your first session.

All information will be kept safe and confidential. All information will be viewed in a compassionate and non-judgemental capacity. Please fill out as much detail as possible. Any questions you do no feel comfortable with answering can be left out.

Bank details for ongoing sessions, and herbal preparations:

Ms E A Taylor

Account No: 75471809 Sort Code: 60-02-38

Reference: Insight 1:1 or Herbs with your name

Please make payment prior to your session, you can also pay by card on the day (with an additional £1 fee) or with cash

Please note I have a 48hr cancellation policy, any less time than this and session need to be paid in full, unless I can arrange to see you at a different time within the same week or can fill you appointment.