top of page
Untitled design(7).png


Please fill out the following form

Please inform your therapist if any of the following are applicable, so that they can alter the treatment accordingly.

Tick any that apply
What areas would you like us to focus on in your session?
Are you experiencing any of the following?
Tick any that apply
Tick any that apply
Do you find yourself experiencing any of the following in the week prior to your period, or any time if you are menopausal
Tick all that apply
Methods of Delivery
Have you Exerienced?
What was your own birth and delivery experience ?
What areas would you like to see changes in?
Tick all that apply

Thank you. Emily Teague

bottom of page