CRIMSON ROOTS
welcome
first mother
why
method
art
reflections
about
faq
contact
intake form
deposit
video meeting
Intake & History
-----Contact Information-----
*
Indicates required field
Full Name
*
Street
*
City, State, Zip
*
Phone Number
*
Email
*
Estimated Due Date
*
How did you find Crimson Roots?
*
-----History-----
Please share a bit about your history and this pregnancy to help us serve you better
This is child #_ for me:
*
History of depression?
*
No personal history
Personal history
Family history
Postpartum
(Pre)menstrual
(check all that apply)
Planned Birth Setting (if hospital, which one?)
*
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)
*
-----Services & Packages-----
All services are performed in-home and include an umbilical cord keepsake
Basic Service $350*
*
Traditionally prepared capsules
Indicate add-ons below
Add-ons
*
Mother's Broth (FREE)
Placenta Tincture ($25)
Art Print in natural sepia ($15)
Art Print with food-based color ($20)
Placenta Healing Salve ($40)
Soothing Reiki, 30 mins ($30)
Moxibustion (warming therapy) ($20)
AromaTouch essential oil application (45 mins, @ 1 month post partum) - ($75)
Complete Care Package $495*
*
Basic Service + all the Add-ons!
with Natural Art
with Color Art
Please select BOTH Basic service box and Art choice. ​Please note in the comments box below if there are any add-ons you would prefer to skip.
*
A variable travel fee may apply to distances greater than 30 miles.
-----Notes and Comments-----
Please leave a note with special considerations or other information pertinent to my ability to best serve you,
including if you have a financial hardship. No one is turned away for the inability to pay.
Comment
*
I'm sorry i will not be able to perform encapsulation on a placenta that has tested positive for hep B/Hep c or hiv/aids - please contact me for alternative options
Please verify by checking below
*
Negative for infectious diseases
I would like to discuss alternative options
"Beyond The Placenta" - An occasional email sharing of healthy lifestyle resources and/or offerings from Crimson Roots
Check box
*
Yes! I want to connect "Beyond The Placenta"
Send
welcome
first mother
why
method
art
reflections
about
faq
contact
intake form
deposit
video meeting