Intake Form

WOMB SURROUND PROCESS workshop INFORMATION form

We recommend reading through each question prior to filling out the application. Some questions may prompt you to research information; and/or contemplate what resonates the most for a response.

YOUR RESPONSES WILL ONLY BE VIEWED BY ALIYAH HAMILTON, AND WILL BE KEPT CONFIDENTIAL

* Indicates required field

Which Workshop and Date are You Applying For? *

Name *

Birthdate *

Email Address *

Primary Phone # *

Home Address *

Mailing Address *

Relationship Status *

What is your intention in exploring your prenatal and birth experiences? *

Professional Information

If you are a bodyworker, psychotherapist, health care practitioner or student in these fields, please indicate the nature of your practice or extent of training (types of therapy). If you do not work in the “healing” arts please give a short account of the work you do. *

Prenatal and birth therapy information

Note: Many of the following questions are intensely personal. Your responses will be kept completely confidential. Filling out this information form actually begins the work of the process workshop. If you are uncomfortable about responding to any of the questions please email or telephone me to discuss this.

Do You Have Children? *

Some of the work may involve physical exertion. Do you have any medical conditions which would contraindicate involvement in this way? *

Do you have any area of your body which needs special consideration? *

Are you presently taking any medications or drugs? (name of medication, for what condition?) *

Submit

YOUR CART

WOMB SURROUND PROCESS workshop INFORMATION form

Professional Information

Prenatal and birth therapy information