crimson roots
welcome
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services
encapsulation
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traditional
placenta+
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reflections
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new client intake
Intake & History Form
-----Contact Information-----
*
Indicates required field
Name
*
First
Last
City/State
*
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?)
*
-----Services & Packages-----
Basic Service and Packages are performed in-home and include an umbilical cord keepsake
Basic Service $275
*
Basic Service ONLY
Basic service and additional services, as indicated
*
Mother's Broth (free)
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 session ($20)
Moxa (Chinese heat application) ($10)
Deluxe Package $350*
Traditional Capsules, Broth, Tincture, Salve, Tea
*
with Natural Art
with Color Art
with Reiki
with Moxa
Placenta+ Deluxe Package $395*
Traditional capsules, CALM, Broth, Tincture, Salve, Tea
*
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
*
*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.
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welcome
why
services
encapsulation
>
traditional
placenta+
art
reflections
about
faq
contact
new client intake