Birthing Your Life Womb Surround Process Workshop
Prenatal and Birth Information Form
Cherionna Menzam-Sills PhD, RSMT/E, RCST
Jerusalem House, Orchard Terrace
Totnes, Devon TQ9 5EY
Telephone: 07801 515865
Email:
Confidential
Name:______Today’s Date______
Birthdate:______Age:______
Occupation______
Address:(including Number/House Name, Street, County, Post Code, Country)______
Telephone: Home______Work______Mobile______
Email______
Note: Many of the following questions are intensely personal. Your responses will be kept completely confidential. Filling out this information form actually begins the work of the process workshop. If you are uncomfortable about responding to any of the questions please email or telephone me to discuss this. Please feel free to write/type on the back or extra pages if needed.
Also, it is important that you have support in relation to the workshop and the material it addresses. Please contact Cherionna before applying for the workshop. It is recommended to have at least one private session with Cherionna prior to the workshop, particularly if you do not have ongoing therapy. This is to support you in having more tools to bring into the workshop, as well as in establishing a working relationship with its facilitator, so you can make the most of your time in the group. The session can be by Skype if in person is not practical.
What is your intention in exploring your prenatal and birth experiences?
Family Relationships (married, partnered, single, divorced, children, grandchildren etc.)
If you have children is there something you would like me to know about their prenatal or birth times?
Professional Information
If you are a bodyworker, psychotherapist, health care practitioner or student in these fields, please indicate the nature of your practice or extent of training (types of therapy). If you do not work in the “healing” arts please give a short account of the work you do.
Some of the work may involve physical exertion. Do you have any medical conditions which would contraindicate involvement in this way? Yes______No______If yes, please explain.
Do you have any area of your body which needs special consideration?
Are you presently taking any medications or drugs? (name of medication, for what condition?)
Are you presently using any recreational drugs, alcohol or nicotine? (amount per day/week).
Have you ever been prescribed medications for mental health reasons? Yes______No______
If yes, please describe the circumstances and outcomes, with the dates.
Have you ever been hospitalized for mental health reasons? Yes______No______
If yes, please describe the circumstances and outcomes, with the dates.
Have you ever experienced suicidal thinking or made a suicide attempt/s? Yes______No______
If yes, please describe the circumstances and outcomes, with the dates.
Are you being treated by any other health care professionals?
Please check what you know or think applies to your birth history. My birth was
_____ anunmedicated vaginal birth at home
_____ anunmedicated vaginal birth in the hospital
_____ a vaginal birth with anesthesia
_____ with forceps
_____with cranial suction (ventouse/vacuum extractor)
_____ with a fetal heart monitor
_____ Ceasarean Section
_____ Breech birth
_____ a multiple birth (twin, triplet)
Other birth complications? Please explain.
Please check what you know or think applies to your prenatal and birth history.
_____ I had a twin that did not live. At what point in the pregnancy or post natal time did the twin leave?
_____ I was premature. How many weeks?
_____ I was in a neonatal intensive care unit. Please state how long, and what you know or think about the reasons for this.
_____I was incubated. Please state how long, and what you know or think about the reasons for this.
_____ I was hospitalized in my first five years of life. If so, please state how long, and what you know or think about the reasons for this. Please note any interventions shortly after birth, high levels of jaundice, or other neonatal complications, or any surgeries or significant illness as an infant or young child.
Who raised you? Were your parents your biological parents? Were you raised by a single parent? If your parents separated or divorced, how old were you? Did you have other major primary care givers like grandparents, aunt and uncles, guardians, foster or adoptive parents?
Do you or did you have siblings? Indicate ages relative to you, and the nature of your relationship as children.
Please relate any other information you know or think concerning your conception, your parents’ attitude toward having you (planned, unplanned, wanted, confused, unwanted etc? If you know you were unwanted, did your parents consider or attempt abortion?).
What was your life in the womb like? Consider physical effects such as : did your mother or father smoke? Consume alcohol or other drugs? Mother’s diet? Also consider emotional effects such as: absence or presence of father during pregnancy and birth? Your parent’s relationship with each other during your pregnancy? Significant stressors or losses during your pregnancy? Your siblings’ attitude to your birth? If you were adopted, give information about the transition to your adopted family as well as any birth history you know.
Have you ever been in an abusive relationship? Yes______No ______If yes, please tell me about it…when, what relation the person was or is to you, whether the abuse was or is physical, sexual and/or emotional? If this was in a past relationship what action did you take? If in a present relationship what are you doing about it? Please give details.
I have access to support and follow up therapy after this workshop if desirable?
Yes_____ No_____ If yes, with whom?______Does this person have pre and perinatal facilitation skills? Yes_____ No______. If you do not have access to follow up therapy, what do you plan to do to support yourself after this workshop? Note: this will also be discussed in the workshop.
If this is your first workshop, who recommended this workshop to you?
I agree to the following (please initial each and sign at the bottom):
______To allow my contact information (name, address, phone number, email, and birth date) to be shared with other participants in this workshop prior to the workshop, or to send an email within two weeks of signing up for the workshop specifying what contact information I do not want shared.
______Taking responsibility for my well-being during and after the workshop.
______Being in good physical, emotional and mental condition and able to participate in the regularly scheduled activities of the workshop.
______Maintaining confidentiality about what takes place in the workshop.
______Reading and agreeing to the logistical information for this workshop, available on the website/flyer; particularly the cancellation policy, and scheduling, including start and end times.
______Attending all scheduled days, arriving on time at the beginning and after lunch breaks, and leaving at the end of the day after the workshop is complete. If flying in, I will plan to arrive at least two hours early in case of airline delays.
______Payment of fees as outlined on the website/flyer.(£100 deposit to secure your place is non-refundable unless facilitator cancels or you are not accepted to the workshop, in some cases it may be transferable to a future womb surround workshop; balance due 30 days before workshop begins)
______Abstaining from alcohol, recreational drugs and nicotine from the day before the workshop until the completion of the workshop including breaks and evenings.
______Not using perfume or aromatherapy or strongly scented shampoos.
Signature______Date:______
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Birthing Your Life