intake form

welcome
- first mother
why
method
art
reflections
about
faq
contact / intake
video meeting

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 uncertain because you have questions, please feel free to call, text or schedule a video meeting.

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

PHONE
413-883-2121

EMAIL
[email protected]

Intake & History

contact information

* Indicates required field

Full Name *

Street, City, State, Zip *

Estimated Due Date *

Email *

Phone Number *

How did you find Crimson Roots? *

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 $325*†

Capsules ONLY no add-ons *

Capsules only, please!

Add-ons with capsules

Capsules PLUS: *

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

Placenta capsules and ALL add-ons : $450!

Complete Care art option: *

Sepia Color

'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.
†Please let me know if you have a financial hardship or need a payment plan

Send

Crimson Roots
Laura Fortin
Holyoke, MA 01040
[email protected]
413-883-2121

welcome
- first mother
why
method
art
reflections
about
faq
contact / intake
video meeting