.: womb wellness intake form :.

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A preliminary introduction to the herstory, the emotional wellness and the overall being of your womb.

These questions range from surface level to very deep and personal, so please create a gentle setting, light a candle and bring peace around you before answering. Take your time, as these can bring up memories.

This practice and inquiry is meant to assist you mama.

Email *

phone number to reach you best?

what's your preferred name?

What city/ state do you live in?

what is your intention for receiving steam?

what are you interested in most?

receiving steam treatment for better general yoni health

learning more about the magic in my womb

coming into right relation with my whole life through womb mysteries

treating a specific condition

Other:

if you are looking to treat symptoms of womb imbalance, what are those symptoms?

amenhorrea (missed periods or inadequate bleeding)

anxiety

clotting

dark blood during cycles

depression

dysmenorrhea (painful cycles)

heaviness in womb area

irregular cycles

irritability with cycles

low libido

pms

unpleasant odor

vaginal discharge

vaginal dryness

fertility issues/ trouble becoming pregnant

pcos

how regular is your moon cycle?

bleeding in accordance with new or full moon, consistently

predictable cycles between 25 - 45 days

periodic spotting between heavy bleeding periods

very inconsistent cycles

unsure

Clear selection

are you currently bleeding or pregnant?

bleeding

pregnant

neither

Clear selection

do you have an iud?

yes

yes, and have intention to take it out

yes, and i have no intention to take it out

Clear selection

are you currently on birth control? if so, what kind?

do you suffer from yeast infections?

yes, often

yes, not often

i have before but have not recently

no, never have

currently have one

Clear selection

when was the last time you gave your body to someone who did not deserve it? do you feel healed from that experience?

what wounds from your ancestry is your womb carrying?

describe your moon cycle

what events of trauma have you experienced?

rape

molestation

domestic violence

verbal

mental

physical

can you share about more of these events, if that feels comfortable for you?

where do you hold the most tension in your body?

have you been pregnant before? if so, did they result in full term births?

did any of those pregnancies end in abortion?

have you miscarried before? if so, how are you feeling?

are you able to squat/ sit on your knees for extended periods?

yes

need physical assistance

Clear selection

do you have allergies to any herbs/ essential oils? if so, which?

what is your typical diet, from rising to resting?

how is your financial abundance? are you able to afford what you need in life? how about what you want?

Are you interested in micro/macrodosing during session? If so, what medicine? lsd, mdma, hape, mushwombs, cannabis

do you have any questions before we meet?

thank you so much for your time creating this form. these are some things you’ll need to gather and prepare for your steam.

• have a journal on hand

• wear a long skirt that you can squat comfortably in

• a clear intention or focus

If you have access to any of these offerings as well, they are deeply helpful:

- honey

- fresh fruit (oranges, lemons, honey, blueberries)

- coconut water or milk

- tobacco

- cacao

- dates

Anything of items similar to these. It doesn’t need to be a large offering 🌙

BE WELL SWEET MAMA

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