Intake Form - Sub Rosa — EarthStar.Birthing

Sub Rosa - Intake Form

Basic Details

Name

First Name

Last Name

Date of Birth

Address

Phone Number

These first set of questions are to help me build up a picture of why you would like to work with Rose and what we may touch on in the sessions

Would you like to work in person or online

In Person

Online

What attracts to you explore working with Rose?

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 some experience with holistic healing or working with healing as a process?

The next set of question are to provide background of your health

Next of Kin (emergency contact details)

Current Medical Conditions / Diagnosis:

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

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:

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

Any additional information?

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.

The block of 3 sessions is £225. This includes Essence of Rose Tincture during the sessions and for you deepen with in between, including p&p for me to send it to you if we are working online

Please pay a deposit of £75 after submitting your form. The remaining balance of £150 is due prior to the first session. If you personal circumstance means you would like a different payment option please do let me know and we can see what we can arrange.

Bank details for payment:

Ms E A Taylor

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

Reference: Sub Rosa