Wild REmemberance Application Name * First Name Last Name Email * How did you hear about this program? Instagram Word of Mouth/Friend Referral Newsletter or Email From Aubrey Directly Other (Please Specify) Date of Birth * MM DD YYYY Place of Birth (City & State) Time of Birth Hour Minute Second AM PM Do you consent to Aubrey pulling your birth/astrological chart? * I'd love that! I'd rather you not. What is calling you to this work at this time in your life? * What do you hope to remember, reclaim, or reconnect with through this experience? * Do you currently have a menstrual cycle? Yes No, I am post-menopausal No, I had a hysterectomy No- for another reason Whether you are currently bleeding or not, please tell us when was your last bleed? Be as specific as possible - ex. Aug 26, 2025, April 2023, Summer 2017. * When was your very first bleed (menarche)? Please be as specific as possible (at the very least, tell us your age or what grade of school you were in). * Are you currently using any form of hormonal birth control? * * If you answered yes to the question above, please tell us what form of birth control and for how long you've been on it. Have you used hormonal birth control in the past? If you answered yes, please tell us what form of birth control, and the years you were on it. Ex. June 2009 - Oct 2017 * Have you ever been pregnant? * Do you have children? * If you have children, do you have any daughters? * Are you currently pregnant, postpartum, or nursing? * If you answered yes, please provide us with any details you feel comfortable sharing. Is your moon cycle consistent in length and duration? * How would you describe the intensity of your bleed? * Light Moderate Heavy Not Applicable What menstrual products do you typically use? (Check all that apply) * Pads Tampons Menstrual Cup Period Underwear Not Applicable Do you experience pain during your moon cycle? If so, on a scale of 1 to 10, how would you rate your pain (10 being the most painful)? * Do you have any diagnosed menstrual health conditions (e.g., PCOS, endometriosis)? * No Yes How does your moon cycle impact your daily life? * * Not at all Slightly Moderatley Significantly Do you feel an emotional or spiritual connection to your menstrual cycle? * Yes No How would you describe your current relationship with your womb? * Sacred Deepening Curious Poor Non existent How aware are you of the different phases of your menstrual cycle (menstrual, follicular, ovulatory, luteal)? * Very Aware Somewhat Aware Not Aware Do you track your cycle or notice energetic shifts throughout the month? * * Yes I track my cycle closely I'm somewhat aware of it Not currently Have you noticed any changes in your cycle recently? (Irregularity, missing periods, increased pain, emotional shifts, etc.) * Yes No If you’d like, share anything about your menstrual, womb, or reproductive journey that feels important. Thank you so much for taking the time to fill out our Wild Remembrance Application!Applications are considered on a first-come, first-served basis. Once your application is reviewed, we will reach out with next steps.We cannot wait to connect with you! 🪶
