Jay Kelly
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    • Hypnosis for Fertility
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    • Seed Cycling for natural hormonal balance
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    • Secondary Infertility
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    • Life after termination
  • Pregnancy
    • The Real Birth Workshop – Harrogate
    • What is Hypnobirthing & will it help?
    • HypnoMothering
    • Birth Fear & Anxiety
    • Birth Doula Package
    • Postnatal Doula Support
  • Postpartum
    • Birth Trauma Relief
    • Trauma after a surrogacy birth experience
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Glow Confidential Intake Form

Home Glow Confidential Intake Form

PRIVATE and CONFIDENTIAL Client Information This form asks for some basic current details, but also goes into some quite personal, and maybe even some challenging information. If you do not want to answer all of these questions, or feel like it is too difficult to at this particular time, then that is absolutely fine. Please fill in what you can and return to me before your appointment if possible (or you’d rather just bring it with you on the day that is also fine). If any of these questions stir up any difficult emotions, please contact me in the meantime. Many thanks, Jay.

  • Personal Details

  • Medical or Other Practitioners

  • Reproductive Health History

  • Former Methods of Contraception

  • Diet and digestion

  • Family History

  • Emotional , Spiritual and Lifestyle

  • On a scale of 0 – 10 (0 being indifferent and 10 being the greatest) please rate yourself on the following:

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  • Please read the Terms and Conditions which will open in a new page.

  • Thank you for taking the time to fill in any of this form. If any of the questions have triggered an unwanted response before your appointment, please get in touch. By filling it in, you are giving me permission to work with you. If any in doubt, contact your GP.

    Message Jay: glowfertility@gmail.com

    Mobile: 07725035047 (sometimes it is not possible to take calls, so emails are preferable)

    Skype clients: glowfertility

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