Womb Surround Process Workshop Form to fill in applying to the Foundation Training
If you haven’t already filled in a form for attending a Womb Surround

Name:	 	Licenses and degrees:	_________
Birthdate:		Age:		Profession:		
Address:		City:	 	State:		Zip:		
Home phone:		Work phone:		Mobile phone:				
Email:				Website: 			

Who recommended this work to you?		

Please describe your family/relationship:
[married/partnered (how long?), children, grandchildren (names for all, age, sex)] 

• If you are a bodyworker, psychotherapist or health care practitioner or student of these, indicate nature of your practice or extent of training. (types of therapy, clients / week)

• What aspect of your early and/or present life would you like to explore during this workshop? What is your intention?

• Some of the training techniques involve physical exertion. Do you have any medical conditions that would contraindicate involvement in such techniques?  Yes           No           If yes, please explain.

• Height, Weight, and do you have any area of your body that needs special consideration?

• Are you presently taking any medications or drugs? (name of medication, for what condition)

• Are you presently using any recreational/ceremonial drugs, alcohol or nicotine? (amount per day / week)

• I have access to follow up therapy after this workshop? If yes, with whom? Does this person have pre and peri-natal facilitation skills? If you do not have access to follow up therapy, what do you plan to do to support yourself after this workshop?

• List other physicians or health care practitioners you are being treated by.

Where were you born?

Please check what you know or think applies to your birth history.   My birth was:______	an unmedicated vaginal birth in a hospital______	an unmedicated vaginal birth at home______	an anesthesia birth______	with forceps______	with cranial suction______	with fetal heart monitor______	c-section ______	breech______	a multiple birth   ______	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.                        ______	I was incubated. How long?  Where was your father during your birth?

Were you separated from you mother at birth (sent to a nursery)? 

Were you breast fed? If yes, how long?

Men, were you circumcised as an infant?

Please note any interventions shortly after birth such as hospitalization for illness or high jaundice, operations, illnesses as an infant or a child. 

Did either or both of your parents lose another child to miscarriage, abortion, stillbirth, or childhood death? If yes, are you aware of how this affected you? Give dates and circumstances.

Who raised you? Were your parents your biological parents? Where you raised by a single parent? If your parents split up, how old were you? Did you have other major primary care givers like grandparents, aunt and uncles, guardians 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 concerning your conception, your parents’ attitude toward having you (planned, unplanned, wanted, confused, unwanted). If unwanted, did they consider or attempt abortion?

What do you know about your life in the womb including physical effects (maternal or paternal smoking, drinking, drugs, mom’s diet), and emotional effects including absence or presence of father during pregnancy or birth, parents’ relationship with each other during your pregnancy, siblings’ attitude toward your birth. If you are adopted, give information about transition in hospital and new family as well as any birth history known. 

Have you ever lost a child to miscarriage, abortion, stillbirth or death? If yes, please explain circumstances and dates and how this affects you today.

Have you ever been or are you in an abusive relationship? If yes, please state when, what relation the person was or is to you, whether the abuse was or is physical, sexual and or emotional. If a past relationship, what action did you take? If present, what are you doing about it. Please give details.

Have you ever been prescribed medications for mental health reason? If yes, please describe the circumstances and outcomes with dates.

Have you ever been hospitalized for mental health reasons? Yes_____No____. If yes, please describe the circumstances and outcomes with dates.

Has anyone in your family ever attempted or committed suicide? If yes, please describe your relationship to the person and the circumstances with dates.

Have you ever contemplated or attempted suicide? If yes, please describe the circumstances with dates.

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 the training prior to Module A, 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 training modules.
______	Being in good physical, emotional and mental condition and able to participate in the regularly scheduled activities of the training modules.
______	Maintaining confidentiality about what takes place in the training modules.
______	Reading and agreeing to the logistical information for this training, available on the website; particularly the cancellation policy, and scheduling, including start and end times and lunch and snack breaks.
______	Attending all scheduled times, checking in on time at the beginning and after lunch breaks, and leaving only after the training module is complete. 
______	Payment of fees as outlined on the website, including cancellation fees.
______	Abstaining from alcohol and nicotine from the day before the training module until the completion of the training module including breaks and evenings.
______	Abstaining from recreational/ceremonial drugs from the time of application to the end of the last module.

Signature:		Date: