Conscious Conception MentorshipInitial Intake Form Name * First Name Last Name Partner Name First Name Last Name In what ways are you most proud of yourself for investing in this Mentorship and your pre-conception journey? * Describe where you are at in your pre-conception journey. * Specific to the last month. Describe what an optimal preconception/conception journey would look like to you. * Describe what you hope to gain from Mentorship? * What are the tangible results you want to physically see in your life by the end of Mentorship? * What are your expectations of me throughout Mentorship? * What are your expectations of yourself throughout Mentorship?? * What do you expect (if anything) to come up as a wall or block and how do you best like to be mentored through it? * What Themes of Wisdom are you "most" excited to learn/implement? Check all that apply. Fertility Awareness + Enhancement Hormonal Blueprint Exploration/Activation Womb Intellect, Connection, Nourishment Cyclical + Lunar Living Quantum Biology + Bioenergetic Practices Pro-Metabolic + Seasonal Nutrition Mineralization + Supplementation Spiritual + Somatic (Breath/Movement) Practices Limiting Beliefs + Mindset Matriarchal Community Decsribe your menstrual cycles over the last 3 years. * Age * Medical History * Include medications (birth control) and supplements. Current Medical Diagnosis Even if considered "unrelated" to fertility and conception, ie allergies. Current Medications and Supplements * Describe your relationship with your body. * Thoughts, emotions when you think/feel your body. Describe your relationship with food. * Thoughts, emotions, when you prepare and consume food. Nutrition Diary * List foods and drinks you have eaten over the last 7 days. Past Symptoms and Stress List ANYTHING that has happened in your physical/mental/emotional life that was not your definition of “optimal." Include when the symptom/stress began and resolved. Current Symptoms and Stress List ANYTHING about your current physical/mental/emotional life that isn not your definition of “optimal." Include when the symptom/stress began. Describe your relationship with your partner and any dynamics you feel may be pertinent to your pre-conception journey. Present? Supportive? Etc. Describe your typical week in regards to work and lifestyle. * Hours Per Day Spent Inside and Outside: * Hours Per Day Spent Moving/Exercising: * Hours Per Day Spent on Technology: * Phone, TV, Computer, Etc. Anything else you would like me to know before our first appointment? Yay. It’s sent. I will forward you a copy as well!Can’t wait for Mentorship to begin!!If you need me before then, please email me.XO
