contact / intake

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contact / intake
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Filling out this Intake & History form is the best way to contact me if you are sure you want your placenta encapsulated. If you are unsure, please contact me by phone or email, or schedule a video meeting.

Everyone is welcome to schedule a video meeting so that we may meet prior to the time of service!

EMAIL
[email protected]

PHONE
413-883-2121

Intake & History

contact information

* Indicates required field

Full Name *

City, State, Zip *

Phone Number *

Email *

How did you find Crimson Roots? *

Street *

Estimated Due Date *

Planned Birth Setting (if hospital, which one?) *

health & history

This is child #_ for me: *

History of depression? *

No personal history Personal history Family history Postpartum (Pre)menstrual

(check all that apply)

Please verify by checking below that you have never tested + for Hep B/C or HIV/AIDS *

Negative HEP/HIV

Do you currently smoke cigarettes OR have you smoked at all during this pregnancy? *

No Yes

If yes, please elaborate (how many per day and for how long) *

Anything else I should know about this or past pregnancies, or any other special considerations? *

services

All services are performed in-home and include an umbilical cord keepsake

New! Optional placenta tincture now included! Previously $25!

Basic Service $295-$350*†

Select here for capsules ONLY *

Traditionally prepared capsules

Add-ons with capsules

Select here for additional services *

Mother's Broth (included! optional) Tincture 4oz. (included! optional) Art Print in natural sepia ($10) Art Print with food-based color ($15) Placenta-infused balm 2oz. ($25) Reiki 30 mins ($30) Moxibustion (warming therapy) ($20) AromaTouch essential oil application (45 mins @ 1 month post partum) - ($75)

Complete Care Package

Save 10% off your total! (discount calculated based on sliding scale)

Choose your art *

CC with Sepia Art CC with Color Art

'beyond the placenta'

An occasional email sharing of healthy lifestyle resources and/or offerings from Crimson Roots

Yes! Let's stay connected *

'Beyond the Placenta'

*A variable fee may apply to extended traveling distances.
†No one shall be turned away for inability to pay. I always encourage a discussion if listed pricing is out of reach for you.

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