Name *

First Name

Last Name

Phone *

(###)

###

####

Session Types

Mark all that apply to your session request.

Mama Sessions

Conception + Cycle Sessions

Video Distance Sessions

Intersted in booking

Single Session

Weekly sessions / 1 Month

Weekly sessions / 3 Months

Preferred Payment *

Venmo

Cash

Card + 5% fee

Date of Last Moon Cycle

First Day of your Last Bleed?

MM

DD

YYYY

Simple Questions for Client Intake & Awareness

Is this your first session doing a steam?

Yes

No

Are you pregnant or trying to conceive?

Yes

No

Are you on any form of birth control?

Yes

No

FAM

Have you experienced a vaginal birth?

Yes

No

Other

Do you currently track your cycle?

Yes

No

Do you have any symptoms characterized with a burning itch?

Yes

No

Are you currently or historically prone to yeast overgrowth in your yoni?

Yes

No

Do you experience any numbness, pain or discomfort in your yoni?

Yes

No

Have you experienced any sexual trauma in your yoni / womb space?

Yes

No

Do you find heat / warmth soothing?

Yes

No

Ad Ons

Intersted in any session add ons?

Womb / Belly Massage

Castor Oil Pack

Salted Foot Massage