crimson roots
welcome
why
encapsulation
art
reflections
about
certificates
faq
contact
new client intake
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.
*
-----Services & Packages-----
All services are performed in-home and include an umbilical cord keepsake
Basic Service $275*
*
Traditionally prepared capsules
Indicate add-ons below
A la Carte Add-ons
*
Mother's Broth (no charge)
Mother Essence Tincture ($25)
Art Print in natural sepia ($10)
Art Print with food-based color ($15)
Placenta Salve ($35)
Reiki, 30 mins ($20)
Moxa (Chinese heat application) ($10)
BEMER Therapy - 2 sessions ($50)
Complete Care Package $425*
*
Complete Care Package
Basic service plus all add-ons
Choose Your Art
*
with Natural Art
with Color Art
-----Notes and Comments-----
Please leave a note about special considerations or other information you feel is pertinent to our ability to best serve you
Comment
*
*
Prices are for local service (within 30 miles of my home). A variable travel fee may apply to further distances.
Please leave a note in the comments if you need a personalized payment arrangement. No one is turned away for the inability to pay.
I'm sorry i will not be able to encapsulate a placenta for anyone who is positive for hep B/Hep c or hiv/aids
Please verify by checking below
*
Negative for infectious diseases
Send
welcome
why
encapsulation
art
reflections
about
certificates
faq
contact
new client intake