PERSONAL INFORMATION

First Name

Last Name

Email Address

Phone Number

Mailing Address

Date of birth

Relationship Status
—Please choose an option—MarriedPartneredSingleDivorcedWidowed

INTENTION AND PROFESSION

Which workshop are you applying for?

What aspect of your early and/or present life would you like to explore during this workshop?

If you are a bodyworker, psychotherapist or health care practitioner or student of these, indicate nature of your practice or extent of training. (types of therapy, clients / week). If you are not in these fields what is your profession?

HEALTH HISTORY

Note: Many of the following questions are intensely personal. Your responses will be kept completely confidential. Do your best to fill the form out as completely as you can. Filling out this form begins the work of preparing your body to begin re-patterning your early imprints. If you have trouble with any of the questions please contact me directly to discuss this.

Sometimes the workshops can involve some physical exertion. Do you have any medical conditions that might make it difficult for you to participate in this?

Are you being treated by any other health care professionals?

Are there any areas of your body that need special consideration?

Are you currently taking any medications or drugs? Please list the names of medications and the conditions they are treating.

Are you currently using any recreational drugs (i.e. cannabis, alcohol or nicotine)? Please indicate amounts per day/week.

Have you ever been prescribed medications for mental health reasons? Please describe the circumstances, dates and outcomes.

Have you ever been hospitalized for mental health reasons? Please describe the circumstances, dates and outcomes.

Have you ever contemplated or attempted suicide? If yes, please describe the circumstances with dates.

Has anyone in your family ever attempted or committed suicide? If yes, please describe your relationship to the person and the circumstances with dates.

Have you ever been in an abusive relationship? If yes, please provide details. When did you have the relationship. Did you have this type of relationship more than once? What was/is your relationship with the person? Was the abuse physical, sexual and/or emotional? If it was a past relationship what did you do about it? If it is a present relationship what are you doing about it?

Do you have access to follow-up therapy after this workshop? If yes, with whom? Does this person have pre and peri-natal facilitation skills? If you do not have access to follow up therapy, what do you plan to do to support yourself after this workshop?

YOUR BIRTH AND CHILDHOOD

Please check anything that you know or think applies to your birth history. My birth:
was an unmedicated vaginal birth at homewas an unmedicated vaginal birth in the hospitalwas a vaginal birth with anesthesiawas a vaginal birth with forcepswas a vaginal birth with cranial suction (vacuum extractor)involved a fetal heart monitorwas a Cesarean Section Birthwas a Breech birthwas a multiple birth - twin, triplet. (Did they live? Answer in the space below.)was premature (By how many weeks? Answer in the space below.)was followed by a stay in the neonatal intensive care unit (For how long, for what issue? Answer in the space below.)was followed by incubation (For how long and for what reason? Please answer in the space below.)

Please provide details about the above birth history selections.

Did either or both of your parents lose another child to miscarriage, abortion, stillbirth, or childhood death? If yes, are you aware of how this affected you? Give dates and circumstances.

Were you breast fed? If yes, how long?

Were you hospitalized in your first five years of life? Please indicate for how long, and what you know or think about the reasons for this. Please note any interventions shortly after birth, high levels of jaundice, other neonatal complications, or any surgeries or significant illness as an infant or young child.

Who raised you? Were your parents your biological parents? Were you raised by a single parent? If your parents separated or divorced, how old were you? Did you have other major primary care givers like grandparents, aunt and uncles, guardians, foster or adoptive parents?

Do you or did you have siblings? Indicate ages relative to you, and the nature of your relationship as children.

Is there anything else you know or feel about your conception? For example: how your parents felt about having you - were you planned, unplanned, wanted, unwanted, were your parents confused about how they felt, did they consider or attempt an abortion, etc.

What was your life in the womb like? Did your mother or father smoke, consume alcohol or other drugs? What was your mother’s diet like? Was your father present during pregnancy and your birth? What was your parents relationship like during the pregnancy? Did your parents experience significant stresses or losses? How did your siblings feel about having a new baby in the family? If you were adopted, how soon after you were born were you adopted? What was that transition time like? What else do you know about your adoption?

YOUR CHILDREN AND BIRTH EXPERIENCES

Do you have children? What were their births like?

Have you ever lost a child to miscarriage, abortion, stillbirth or death? If yes, please explain circumstances and dates and how this affects you today.

AGREEMENTS AND CONSENT

Please read and indicate that you understand and agree with the terms of attending a process workshop:
I take responsibility for my well being during and after the workshop
I am in good physical, emotional and mental condition and can participate in the regularly scheduled activities of the workshop
I understand that all the shared material that I learn from other participants in the workshop is totally confidential
I agree to not be involved in any sexualized way with any other participants during the process workshop, unless we came to the workshop as a couple
I agree not to consume alcohol or recreational drugs during the workshop

Please check this box to verify that you have given us your permission to collect this information