Womb Healing Program Intake Form

The purpose of this form is to understand what is the key area of focus for the Womb Healing sessions with Allera Dawn.

First Name*
Last Name*
Email*
Phone*
Skype
Timezone

How did you hear about Allera?
Are you currently working with or scheduled to work with a coach/ healer/ therapist? YesNo
If so, please provide details:

What's your key area of focus for Womb Healing?
How is this affecting your life presently?
What steps have you taken towards resolving this issue so far?
What's your biggest fear in reclaiming your Divine Feminine power?
On a scale of 1 - 10 (10 being the highest) how committed are you to your own self growth right now?
What specifically would be of the most value to you in working with Allera?
How much time can you dedicate each day to your meditation/planning/journaling as part of the healing process? None- I’m too busy0- 30 minutes30-90 minutesI’m willing to commit the time to process and integrate the healing I receive. Even if this means changing my current routine to accommodate it

What type of self development work have you tried? CoachingTherapy (Psychotherapy/CBT)Hypnosis/meditationReiki/Soul Realignment/Theta HealingI trust my intuition more than anything else
What type of treatments have you tried in connection to your issue? AcupunctureHypnosisBodyworkEnergy healing (eg Reiki/Cranio sacral therapy)NutritionistHomeopathSpiritual healing (healers/shaman)Conventional medicineOther
If other, please detail

Is there anything else you would like to share: