crimson roots
welcome
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encapsulation
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traditional
placenta+
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Intake & History Form
-----Contact Information-----
*
Indicates required field
City, State
*
Name
*
Zipcode
*
Phone Number
*
Email
*
How did you hear about us?
*
-----History-----
Please share a bit about your history and this pregnancy to help us serve you better
Estimated Due Date
*
This is child #_ for me:
*
History of depression/mood disorder?
*
No personal history
Personal history
Family history
Postpartum
(Pre)menstrual
(check all that apply)
Planned Birth Setting (if hospital, which one?)
*
All services are performed in-home and include an umbilical cord keepsake
-----Services & Packages-----
Add-ons
*
Mother's Broth (no charge)
Mother Essence Tincture ($25)
Placenta+ (please inquire)
Art Print in natural sepia ($10)
Art Print with food-based color ($15)
Placenta Salve ($35)
Medicinal Tea Preparation ($10)
Reiki, 30 mins ($20)
Moxa (Chinese heat application) ($10)
AromaTouch - 45 mins ($45)
BEMER Therapy - 2 sessions ($40)
Basic service and add-ons, as indicated
Deluxe Package $350*
Basic Service $275*
*
Capsules only (select add-ons below)
Choose Any
*
with Natural Art
with Color Art
with Reiki
with Moxa
Capsules, Broth, Tincture, Salve, Tea
Placenta+ Deluxe Package $395*
Choose Any
*
with Natural Art
with Color Art
with Reiki
with Moxa
-----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
*
Capsules, CALM, Broth, Tincture, Salve, Tea
*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.
Send
welcome
why
services
encapsulation
>
traditional
placenta+
>
sample
art
reflections
about
faq
contact
new client intake