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Integrative Pelvic Health Client Intake Form

Everything exchanged through this form will be kept confidential unless you ask us to share it with third parties.

Thank you for taking the time to complete this form. It is an important initial step in the journey we take together. Be sure to pay attention to any emotions, feelings, sensations, dreams, coincidences and other clues that may arise in your life during this time.

Looking forward to reading your responses and beginning our work together!

Full Name:

Age:

Email:

Phone:

Based in:

Date of form completion:

What do you wish to work on during our time together?

Which challenges do you wish to move beyond at this time?

What is your relationship to your pelvic space, energetic and physical?

What is your relationship to your heart space and rib cage?

How much do you feel guided by your intuition in your daily life?

Have you done any physical work with your pelvis? If so, what kind of work, and how was the experience for you?

What is the outcome you wish to call in through this session?

How is your relationship to your monthly cycle/period? If you’re not getting a period how was it when you were?

How do you feel about the balance between your inner masculine and your inner feminine?

What inner gifts do feel called to (re-)claim and bring into the world?

How do you feel about your connection to your ancestral guidance?

What transformations and manifestations would you like to see happening in your life?

Do you currently have any medical conditions, physical, mental or otherwise, or a history of such conditions?

Is there anything else you wish to share that you believe is important?

By submitting this form. I accept that the information entered will be used within the strict framework of my request.

Integrative Pelvic Health Client Intake Form

Everything exchanged through this form will be kept confidential unless you ask us to share it with third parties.

(03) 9034 5997

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