Intake Form - Being Present to what is Mini Course

Being Present to what is - Mini Course

I ask you to give us some basic health information to ensure that there are no contraindications when working with the plants.

This form must be completed, and payment received by the 31st January at the latest for me to send Essence of Rose of you in time for the first live session

Payment:

Pay by 20th January for 25% off - £75

Full Price - £100

Account Number: 75471809

Sort Code: 600238

Account Holder: EA Taylor

Reference: BeingPresent

Thank you

All information will be kept safe and confidential. All information will be viewed in a compassionate and non-judgemental capacity.

Any queries please get in touch

Emily - 07889996477 / emily@earthstar-birthing.co.uk

Name

First Name

Last Name

Email

Postal Address

Please tell me about any significant medical conditions and any medication you are on:

Do you have any allergies or any reason to believe you may be allergic to a plant:

Do you have any experiences of mental health challenges either past or present:

Are you pregnant or Breastfeeding:

Do you have a sensitivity to Alcohol

The Essence of Rose contains alcohol tincture. Most of the alcohol will evaporate when mixed with boiling water, but do let me know if you need to avoid alcohol completely, and I will send you an alternative

Yes

No

What inspires you to take part in this course?

Please let me know if you are happy to be added to my mailing list

Yes

No