Castellino Certified Womb Surround Prenatal & Birth Process

Ref: Fees/DMH/060708/UK
Castellino Certified
Womb Surround Prenatal & Birth Process Workshop
Facilitated by David Haas
Thank you for your interest in taking a workshop with me.
Please find below an application form. The form has been laid out to facilitate my understanding of the
information you have taken time to provide so please do not alter the format. It may take you some time to
answer the questions and it is important to complete the form as fully as possible. Although I appreciate that
you may not have all of your birth or certain other early life information, some of the information you may
be able to obtain from your family. Please note that you are required to complete pages 1 and 2 in full and
ensure that you sign and initial where requested. The information that you provide in this application form
will be treated as confidential.
Once completed return it to me at First Expression, including a recent colour passport photo of you.
Alternatively you can either email it as an attachment or fax me. You can send a facsimile to the phone
number below. If you send a facsimile listen first to see if I answer or if the voicemail answers. If the latter
you can press your start key and the facsimile will be transferred to my voicemail. If you choose to email
your form, contact me first.
Once I have received your form I will contact you to arrange a time for you to contact me by phone so that
we can go through the application form and for you to get any additional information about the workshop.
It is only once this process is completed that we can decide if this workshop will be suitable for you. For this
reason please do not book any non refundable travel etc.. until your place is confirmed.
Send your non refundable deposit of £100, or alternatively the full fee as described overleaf, directly to the
administrator of your workshop. If you have sent me your application form by facsimile please include a
paper copy with your photo when you send your cheque. (If it is not possible to offer you a place on this
workshop at this time the deposit/ full fee will either be returned to you or can be transferred to a future
workshop).
Information about the venue and local accommodation is available from the website.
Should you need any clarification about the workshop, the form, or just wish to speak with me please
contact me at the telephone numbers/ e-mail below.
I look forward to hearing from you.
With kind regards
David Haas
RPP, RCST, Cert Prenatal & Birth
Fees
Payment Structure
There are two payment forms.
(a)
(b)
Payment in full at the time of application. (This is inclusive of your £100 non refundable
deposit).
A non refundable deposit of £100, which secures your place with the balance due being received
by no later than 4 weeks in advance of the start date of the process workshop. If the balance is
not received by this time, and you have not agreed otherwise with David Haas, then your place
will not be held and your deposit lost.
Method of Payment
You may pay either by check, money order, transfer, or cash and credit card. Checks and money orders
should be made out to David Haas and sent directly to him. Note that any bank charges incurred as a result
of the method of payment are your responsibility.
Cancellation
In the event of you having to cancel you automatically forfeit the £100 non refundable deposit. Depending
on when you cancel will affect your cost. Please note that the date of cancellation is considered the date that
David confirms your cancellation. If you choose to use email and you do not receive a response within 24
hours please follow it up with a phone call.
Cancellation fees which include the non refundable deposit
x
x
In excess of 4 weeks notice
Less than 4 weeks
£100
Full workshop price
If the workshop fills then you will only be liable for the non refundable deposit.
P r o c e s s W o r k s h o p Application Form,
Workshop Date
Name
Profession
Birth date:
Age:
Country of Birth
Address
City
County
Post Code
Phone:(home)
Phone (Work)
Mobile/ Cell
E-mail
Home fax
Work fax
Who recommended this work to you?
If you related to someone who is also applying for this workshop please provide his/ her name & nature of
relationship
Family/relationships (married / partnered children grandchildren)
If you are a body worker psychotherapist or health care practitioner or student of these indicate nature of your
practice or extent of training. (Types of therapy clients / week)
What is your purpose and intention for taking this workshop? (If more space required use last page of doc and refer to it)
Some of the workshop techniques involve physical exertion. If you have any medical conditions that would
contraindicate involvement in such techniques please explain.
Height
Weight
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 drugs alcohol or nicotine? (Amount per day / week)
I have access to follow up therapy after this workshop?
Yes
No
If yes with whom?
If this person does not have pre and peri natal facilitation skills and 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.
Name:
Page 1 of 6
Please initial the following:
I take responsibility for my well being during and after the workshop.
I am in good physical, emotional and mental condition and can participate in the regularly scheduled activities of
the workshop
I understand that I am required to attend each day of the workshop from the agreed start time until the
workshop finishes each day. [It is therefore strongly recommended that if travelling from a distance that you arrive the day
prior to the workshop. Also that you do not plan on travelling on thesame day the workshop completes.]
I agree to abstain from alcohol and recreational drugs from the day prior to the workshop until the
completion of the workshop, including during breaks and evenings.
I agree to abstain from nicotine within the venue and will do my best to abstain from it from the day prior to the
workshop until the completion of the workshop, including during breaks and evenings.
I agree to maintain confidentiality about what takes place in the workshop.
I agree to the payment of fees as outlined in the covering letter ref Fees/DMH/060708/UK.
Signature
Date:
Please list below all Castellino Birth Process Workshops that you have attended over the last 4 years. If you require
more space continue on a separate sheet, ensure your name is clearly visible and delete as applicable below.*
Date
Continued on a separate sheet
Name:
Location
Facilitator/ Co- Facilitators
Yes/ No*
Page 2 of 6
Please check what you know or think applies to your birth history. My birth was:
An unmedicated vaginal birth in a hospital
Induced
An unmedicated vaginal birth at home
With foetal heart monitor
An anaesthesia birth
C-section
With forceps
Breech
With cranial suction
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?
Yes
No
Were you circumcised as an infant?
Please note any interventions shortly after birth such as hospitalisation 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 natural 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, nature of relationship as children.
Name:
Page 3 of 6
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.
If you have ever lost a child to miscarriage, abortion, stillbirth or death please explain circumstances and dates
and how this affects you today.
Name:
Page 4 of 6
If you have ever been, or you are currently in an abusive relationship 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.
If you have ever been prescribed medications for mental health reason please describe the circumstances and
outcomes with dates
.
If you have ever been hospitalised for mental health reasons please describe the circumstances and outcomes
with dates.
Has anyone in your family ever attempted or committed suicide?
Have you ever contemplated or attempted suicide?
If yes to either of the above, please describe the circumstances with dates.
Name:
Yes
Yes
No
No
Page 5 of 6
F a m i l y a n d o t h e r r e l e v a n t History t h a t h a s n o t b e e n i n c l u d e d a b o v e
Resources
What in your life gives you enjoyment?
Signature
Name:
Date:
Page 6 of 6