Integrative Womb Hara Ceremony

Request edit access

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Dear sister,

I am so humbled and grateful you have found your way to this sacred work. Please take your time in responding to the questions on this form to ensure full safety, alignment, and support are every part of this journey together. I look forward to connecting soon.

Thank you so much.

With love,

Patricia

Email *

Name & Phone Number ( I will text message for next steps ) *

Scheduled ceremony date and case study session # (example; May 5th, 2026 - case study session #1) *

Address *

Date of Birth *

YYYY

What called you to this sacred womb work and do you have any primary concerns? *

Do you have a desired outcome for your session/experience? *

Do you experience healthy menstrual cycles? irregular cycles? What is your typical cycle time frame? Please share with detail. *

When was your last bleed and when is your next scheduled start date *

Have you experienced sexual trauma/abuse at any age? You may answer with yes/no/unsure or share as much detail as you feel called to sharing. *

Do you currently experience anxiety? If so, can you share: where does the anxiety live in your body? what type of thoughts do you experience with anxiety? how often are you experiencing? *

CONTRAINDICATIONS: Please check off any that apply *

IUD / Fitted Coil

Recent abdominal or pelvic surgery (within 8 weeks or less)

Possibility of pregnancy

Within 2-3 days of your next moon cycle and your scheduled session

Heavy period bleeding

Actively trying to conceive

IVF

Required

MENSTRUAL & FERTILITY HISTORY: Please check all that apply. *

Painful periods

Painful ovulation

Irregular periods

Heavy bleeding

Fibroids

Endometriosis

PCOS / PCO

Miscarriage

Cervical Cancer

Hysterectomy

Fertility Issues

n/a

Other:

Required

PREVIOUS PREGNANCY & BIRTH: Please number and share with as much detail as possible

1. Have you ever been pregnant?

2. Number of deliveries?

3. Methods of delivery?

4. Birthing experience

5. Did you experience any birth trauma?

6. Miscarriage

Do you have any information or understanding of your own birth story? If so, what do you know? *

MEDICAL HISTORY: Please check all that apply *

Have had abdominal, pelvic or lower back surgery

Experienced accidents or physical trauma

Have fallen on sacrum, tailbone, neck or head

Current Pelvic, hip, low back pain

n/a

Required

DIGESTIVE HISTORY: Please check all that apply *

Constipation (<1 per day)

Diarrhea

IBS

Abdominal pain

Diagnosis of specific organs

Painful areas front/back of mid section

n/a

Required

Please list any numbers on this diagram where you experience pain or discomfort:
*

Is there anything else you would like to share in preparation for our time together? Emotionally, Physically, Mentally, Spiritually.... anything at all <3 *

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Forms