Name
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First Name
Last Name
Email
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Phone
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How did you hear about Zwicker Healing Arts?
What is your intention for pelvic steaming?
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How would you like to feel after our sessions?
Is this your first time doing a steam session?
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Are you currently trying to conceive or on a fertility journey?
Are you currently, or have you been on any form of birth control?
Have you ever been pregnant?
Did you carry to term? Vaginal birth or c-section? History of miscarriage/abortion?
When was your last period? Share a little around your overall period/cycle health
Tell us a little about how your cycle, heavy bleeding, how many days between periods, cramps, painful etc..
Have you had 2 periods/month (ie a period every 19 days or less) within the last three months?
Yes
No
Not Sure
Is there anything else you'd like to share about your fertility journey?
Are you taking any medications or herbs? If so please list.
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Any recent surgeries or injuries? If so please explain
Do you suffer from chronic pain? If so please explain.
Check All That Apply
Please explain any of the conditions you have marked above
Do you have a history of cancer? If so, Any past surgeries or treatments that might have damaged lymph nodes?
Is there anything else you want Sydney to be aware of?
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Because of the intimate nature of this work, please let Sydney know if there is anything in your history of touch that she should be aware of. We can discuss this during our in-person intake, but it is an important as we will be working with the pelvis and the genital region. We want to co-create a safe container for your healing process.
Cancelation Policy
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When an appointment is scheduled this time is reserved specifically for you. Session spots are limited and highly coveted. To reschedule 48 hours notice at a minimum is required otherwise the full session will be marked as used. Failure to give 48 hours notice will result in being charged for the session in full except in a situation where there is a true unexpected emergency (this is always discussed)
I voluntarily request and consent to receive massage therapy and pelvic touch bodywork from Zwicker Healing Arts LLC. In signing below, I understand and agree to the above.
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Client Signature - By writing my name below, I agree that the above information is correct.
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