Womb Reclamation Intake Form

Thank you for taking the time to complete this form. I will review your responses and look forward to meeting you soon.

Sharing this info helps me understand you better and ensures our sessions are helpful for you.

Your answers will remain confidential and will not be shared with any third party.

What inspired you to explore a womb reclamation session at this time?

Please describe what attracted you to this healing process.

What are the primary issues or challenges you are experiencing in relation to your womb space, creativity, or feminine energy?

For example: physical discomfort, emotional blockages, feeling disconnected, etc.

Have you experienced any trauma, physical pain, or emotional challenges related to your womb or feminine energy in the past?

If yes, please share any details you feel comfortable discussing:

What are your intentions for this reclamation session?

E.g., releasing stored emotions, deepening your connection with your inner wisdom, awakening creative energy, etc.

Have you participated in any womb healing or energy healing sessions before?

If yes, please briefly describe your previous experiences:

Do you have any current health conditions or physical limitations that I should be aware of?

Please detail any relevant information to ensure a safe and supportive session.

Is there anything else you’d like to share about your journey or your goals for this healing experience?

Name

First Name

Last Name

Phone

(###)

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Thank you!