Which Workshop and Date are You Applying For?
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Name
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First Name
Last Name
Birthdate
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MM
DD
YYYY
Email Address
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Primary Phone #
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Home Address
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Relationship Status
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Married
Partnered
Single
Divorced
Widowed
What is your intention in exploring your prenatal and birth experiences?
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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.
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Do You Have Children?
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Some of the work may involve physical exertion. Do you have any medical conditions which would contraindicate involvement in this way?
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Do you have any area of your body which needs special consideration?
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Are you presently taking any medications or drugs? (name of medication, for what condition?)
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Are you presently using any recreational drugs: cannabis, alcohol or nicotine? (amount per day/week)
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Have you ever been prescribed medications for mental health reasons?
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Have you ever been hospitalized for mental health reasons?
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Have you ever experienced suicidal thinking or made a suicide attempt/s?
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Are you being treated by any other health care professionals?
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Please check what you know or think applies to your birth history. My birth was:
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Please Enter Details From Above Selection as Needed
Were you hospitalized in your first five years of life. If so, please state how long, and what you know or think about the reasons for this. Please note any interventions shortly after birth, high levels of jaundice, or other neonatal complications, or any surgeries or significant illness as an infant or young child.
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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?
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Do you or did you have siblings? Indicate ages relative to you, and the nature of your relationship as children.
Please relate any other information you know or think concerning your conception, your parents’ attitude toward having you (planned, unplanned, wanted, confused, unwanted etc? If you know you were unwanted, did your parents consider or attempt abortion?).
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What was your life in the womb like? Consider physical effects such as : did your mother or father smoke? Consume alcohol or other drugs? Mother’s diet? Also consider emotional effects such as: absence or presence of father during pregnancy and birth? Your parent’s relationship with each other during your pregnancy? Significant stressors or losses during your pregnancy? Your siblings’ attitude to your birth? If you were adopted, give information about the transition to your adopted family as well as any birth history you know.
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Have you ever been in an abusive relationship? If yes, please tell me about it…when, what relation the person was or is to you, whether the abuse was or is physical, sexual and/or emotional? If this was in a past relationship what action did you take? If in a present relationship what are you doing about it? Please give details.
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Please read and mark that you understand and agree with the terms of attending a process workshop:
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Who recommended this workshop to you? Finally, PLEASE SIGN WITH YOUR FULL NAME AND TODAYS DATE. Thank You for Your Interest!
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