Intake Form

Before each of my initial visits with my prospecting clients, I ask them to fill out an intake form to cover basic details. This gives me a larger understanding as to what your needs are and how I can best help you. If we have scheduled your virtual visit, please fill out the form below. If we have not spoken yet, but you are interested in my services, you are welcome to fill out the form below, and I will contact you within the week to schedule your complimentary visit.

First name

Last name (Optional)

Phone (Optional)

Due Date

Where do you plan to deliver? If at home, please list your city/town:

Who is your practitioner? (Optional)

Baby's Gender: (Optional)

Baby's Name: (Optional)

Have you given birth before? If yes, please explain how you felt about your experience:

Have you been pregnant before?

Have you taken childbirth classes? If yes, please list them: (Optional)

Have you taken breastfeeding classes? If yes, please list them: (Optional)

Please list the names of any support people you wish to have present at your birth and your relationship to them:

Do you plan to use medication? If so, please list them:

What are the 3 most important things for your birth? (ie. I want my partner present, I want music playing during, I want sushi DoorDashed to me immediately postpartum, etc.)

Apart from unexpected emergencies, what worries you the most about your birth?

Do you have any health concerns regarding your pregnancy and/or birth? (ie. VBAC, preeeclampsia, high blood pressure, etc.)