Womb Continuum Workshop
About
Sessions
Intake Form
Contact
Book Now
Womb Continuum Workshop
About
Sessions
Intake Form
Contact
Creating within The Original Template Of Being Created by Frank Carbone
Book Now
WOMB CONTINUUM PROCESS WORKSHOP INTAKE
Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email
*
Age
*
DOB
*
MM
DD
YYYY
Profession/past profession/Licenses/Degrees:
How did you hear about this workshop? Who recommended it to you?
What interested you in attending the workshop? What might you be looking to receive for yourself?
Please describe your family/relationships, including partner, children, grandchildren, others significant in your life.
What kinds of psychological or bodywork therapy have you experienced or training you have had – either currently or in the past? For what period of time? And with whom?
Will you have access to follow up therapy after the workshop?
YES
NO
With whom?
Do these practitioners have pre & peri-natal facilitation skills?
YES
NO
Some of the workshop techniques involve physical movement and exertion.
Do you have any areas of your body that need special consideration? Or do you have any medical conditions that would exclude you from physical activity in a session?
YES
NO
If YES, please explain.
Height:
Weight:
Are you presently taking any medications or drugs?
YES
NO
Please provide name of medication, for what condition, for what period of time.
Are you presently using any recreational or ceremonial drugs, including alcohol, nicotine?
YES
NO
Please provide amount per day/week/month.
Please list other physicians or health care practitioners who are treating you.
Please list any other support you have.
PRE- & PERINATAL HISTORY
What information do you know concerning your conception and your parents’ attitude toward having you? For instance, was your conception planned, unplanned?
What happened when your parents discovered the pregnancy? How did they respond? Were they clear, excited, confused, ambivalent, concerned? What did they consider when they learned about you? (e.g., life-style changes, adoption, abortion, etc?)
What do you know about your life in the womb, including physical influences (maternal or paternal smoking, drinking, drugs, stress, mom’s diet), and emotional effects (absence or presence of partner, parents’ relationship, siblings’ attitude, stressors)?
If you are adopted, please include any information about the transition: in hospital, involvement of both sets of parents, as well as any birth history known.
Did either or both of your parents lose another child to miscarriage, abortion, stillbirth, or childhood death? Please include dates and circumstances of the loss(es). Also, if yes, are you aware of how this affected you?
BIRTH HISTORY
Please check what you know or think applies to your birth:
a vaginal birth in a hospital
a vaginal birth at home
unmedicated
c-section
breech
a multiple birth
with pitocin/induction drug
with fetal heart monitor
with anesthesia
with forceps
with cranial suction
other birth complications/interventions/drugs, please explain:
Please check what applies to your prenatal, birth, perinatal history:
I had a twin that did not live.
I was in Neonatal Intensive Care Unit (NICU).
I was in an incubator.
I was resuscitated.
I was separated from my mother after birth.
I was sent to a nursery.
I was breast fed.
I was bottle fed.
I was circumcised.
Please explain your choices:
Who was present at your birth? Family members, friends, medical or support personnel?
Where was your father during the birth?
Please describe any other interventions administered shortly after your birth such as hospitalization for illness or high jaundice, surgeries, illnesses as an infant or child.
ADDITIONAL INFORMATION
Who raised you? Natural/biological parents? Adoptive parents? Single parent? Please also include other major primary care givers (like grandparents, aunts, uncles, guardians, nannies)?
Are your parents still together? If they have separated, how old were you? How did this impact you and your relationships with each parent?
Do you or did you have siblings? Please indicate ages relative to you and the nature of your relationship with them as children and now.
Have you ever lost a child to miscarriage, abortion, adoption, stillbirth, death?
YES
NO
If yes, please explain circumstances, dates and how this affects you today.
Have you ever been or are you in an abusive relationship?
YES
NO
If yes, please state when, what relation the person was or is to you, whether the abuse was or is physical, sexual or emotional. If a past relationship, what action did you take? If present, what are you doing about it? Please give details.
Have you, or anyone in your family, ever been: diagnosed with mental health issues, e.g. bipolar, schizophrenia, depression, etc prescribed medications for mental health issues? hospitalized for mental health reasons? If yes, please describe who, and be as specific as you can with diagnoses, prescriptions, hospitalizations, and the circumstances and dates of each.
Has anyone in your family ever attempted or committed suicide?
YES
NO
Have you ever contemplated or attempted suicide?
YES
NO
If yes to either of the above, please describe the circumstances and dates.
Please describe anything else about your history that might be relevant for us to know?
I agree to the following (please check each and sign at the bottom):
*
To take responsibility for my own wellbeing during and after the workshop. This includes seeking follow up support if needed.
That I am in good physical, emotional and mental condition and able to participate in the regularly scheduled activities of the workshop.
To maintain confidentiality about what takes place in the workshop.
To commit to attend all scheduled days and hours, arriving on time at the beginning and after lunch and breaks, and leaving at the end of the day after the workshop is complete. If traveling or commuting, I will plan accordingly.
To make full payment of all fees as outlined.
To abstain from the use of alcohol, recreational drugs and nicotine from the day before the workshop until the completion of the workshop including breaks and evenings.
To not use perfume, aromatherapy, or strongly scented shampoos or lotions.
Signature:
*
Date:
*
MM
DD
YYYY
Thank you!
Thank You
Frank Carbone.
