Womb and Hara Relational Healing Intake Form
Thank you for the time and attention you are giving to this questionnaire. Each individual and partner only needs to fill it out this one time, prior to your first session with Dhyana and/or Freddie Kluth.

This is the first step of the inward journey we are taking together, so be aware of any feelings, dreams, coincidences, and clues that arise. They will be important to your healing the unconscious conflicts, unresolved issues or traumas influencing your relationships and experience of life.

If it feels difficult to answer any of the questions, place your hands on your lower abdomen, breathe down to connect in – or make yourself a cup of tea and let the questions percolate. If nothing comes, don’t push or force, just allow space for a mysterious blank of possibility and note the first thing that comes to mind. We look forward to reading what you have shared, and speaking with you soon.

With Love,

Freddie and Dhyana Kluth
Womb and Hara
www.wombandhara.org
FreddieDhyana@gmail.com
917-806-7384 | 917-312-1172


Note: All details of this questionnaire, including your contact information, are part of your personal and confidential record. They are shared with no one other than Freddie and Dhyana Kluth unless you specifically authorize it.
Email address *
Untitled Title
Full Name: *
Your answer
Age: *
Your answer
Phone: *
Your answer
Present location: *
Your answer
Personal details: In Sacred Relationship? Blessed with children? Sacred vocation/current work? *
Your answer
Current Issues: Close your eyes, breathe, and ask yourself what issues are most important for us to talk about in our session? What are your most important goals? *
Your answer
Medical History: Have you experienced any medical issues in the past, and when did they happen? Please include emotional and psychiatric issues (e.g. depression, suicide attempt, bipolar, anxiety, hospitalizations, etc) Are you currently taking any medications? *
Your answer
Family History: What significant emotional issues or problems do/did your parents and siblings have? Alcoholism or addictions? Experiences of sexual or emotional abuse? *
Your answer
Have you had any of the following traumas: Miscarriages? Abortions? Hysterectomy? Sexual abuse or molestation? Death of family members? Long-term relationship/marriage breakdown? *
Your answer
Conception and Gestation: What was your mother’s first reaction when she found out she was pregnant with you? (you may not know this with your mind, but often you have an innate feeling) Did your mother feel supported, loved, safe during pregnancy with you? Did her family support her? Your father? Did your mother have any traumas, losses, depression, major stresses, work stress or financial worries during this time? *
Your answer
Birth: Did you experience any birth traumas or early separation form your mother? Pre-term birth? C-section? Forceps delivery? Chemical induction of labor (pitocin)? Fear around birth? Post-partum depression? Were you breastfed? *
Your answer
Childhood Experiences: How was your relationship with your mother as a child, from an emotional perspective? Your father? Was either parent physically or emotionally absent, abusive or cruel or overly controlling? Did your parents attune to your emotional needs? Or, did you have to attune to their emotional needs to keep them emotionally stable and happy? Did either parent shame your sexuality or body, or try to control its expression? Were you permitted to express anger or cry in front of your parents? Were they supportive of your emotional expression? *
Your answer
Intimate Relationships: What was your first experience with sex / sexuality like when you were young? Honoring? Innocent? Loving? Or not? Are you in an intimate relationship now? How many times in an average month do you make love? Are you satisfied with your lovemaking? If you are not in an intimate relationship now, have you been in one in the past? How long ago? Have you ever been in an abusive relationship (emotional or physical)?What is your greatest grief in your relationship with the internal and/or external masculine/feminine? *
Your answer
Emotional Expression: Are you comfortable expressing anger? Are you able to express anger on your own? Around other people? Are you comfortable expressing grief or sadness? Are you able to cry on your own? With others? Are you comfortable expressing your sexual energy?Can you assert your own needs and desires around others? Or do you find yourself doing what others want or expect of you, rather than what you desire? *
Your answer
Womb and Hara enquiries for women and men (Women and Men, you may both tune into your inner feminine and inner masculine energy and respond to these questions intuitively): What gift do you wish to claim by opening to your femininity/masculinity and sexuality? What is your greatest fear to opening your true femininity/masculinity and sexuality? How was your menarche (first menstruation)? How was your journey into puberty and the positive/negative experience around your first ejaculation? How does orgasm and menstruation or menopause feel to you? Ask Womb or Hara … What is your greatest grief in your relationship with your feminine/masculine self? How do you feel about your body? Do you ever judge or control her/him? *
Your answer
Relationship to Spirit: Do you have a relationship with Spirit, Divine Mother, God, or similar? Do you feel Spirit loves and supports you? Or, do you feel disconnected or abandoned? *
Your answer
Dreams, Desires and Vision: What are your deepest desires and dreams for your life? Do you have a sense of your ‘Soul Purpose’ or gifts to share with the world? What brings you Joy? (Take a moment to close your eyes, take some deep breaths and connect deeply into your essence before answering.) *
Your answer
Is there anything else you feel is important to share? *
Your answer
Repair the rift of separation consciousness and heal spiritual trauma to free your innocent, powerful, creative wild nature!
A copy of your responses will be emailed to the address you provided.
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