Intake FormPlease complete the following form after we have met in person and signed a contract. Contact me for a free consultation Birther's Name * First Name Last Name Birther's Email * Birther's Phone * (###) ### #### Partner / Support Person's name First Name Last Name Partner / Support Person's Email Partner / Support Person's Phone (###) ### #### Emergency Contact (Name / Relationship / Phone number) * Estimated Due Date / Period * Care Provider * Birthing Location * Have you taken a tour of your birthing place? Yes No I plan to Pregnant person's allergies (food / medications) * Please list any medical conditions prior to conception that would impact pregnancy or birth. Any medical conditions developed during pregnancy: * None Gestational Diabetes Group B Strep Severe Insomnia Anxiety Depression Hyperemesis Gravidarum (severe morning sickness) Anemia Heartburn Headaches Pica Back Injury / Pain Preeclampsia Other How much, and how well are you sleeping during this pregnancy? What number pregnancy is this for you? 1 2 3 4+ Number of previous births 1 2 3 4+ Please list the number of living children and their ages: Please describe your physical and emotional prenatal and pregnancy experience so far: Have you taken a childbirth education class? Please list date and location. Do you plan to take any additional childbirth / newborn education classes? Please list date and location. Please tick any topics you would like to discuss further: Ways labour can begin Early labour signs and signals Stages of labour Timings and contractions Natural comfort strategies / pain management Breathing techniques Positions for labour Unmedicated / Medicated labour and birth Induction General triage procedures Common medical procedures in labour Pain medications / medical interventions in labour Positions for pushing Episiotomy Assisted vaginal delivery Cesarean delivery Post birth procedures Newborn procedures Postpartum healing Postpartum support planning Feeding and breastfeeding Newborn care Postpartum mood disorders Postpartum nutrition Are you or your support person reading any books on pregnancy / childbirth / postpartum or breastfeeding? Please list below. Do you have a postpartum support plan? Postpartum support plan team Family Friends Postpartum Doula Partner Lactation Consultant Please check any topics you would like to discuss further: Care of perineum Postnatal expectations C-section recovery VBAC-specific information Breastfeeding Breast pumps Postpartum depression Infant massage Diet Circumcision vs. intact Car seat installation and use Baby wearing What is your birth vision? If things go perfectly according to this vision, describe what this looks and feels like for you. Have you made a birth plan / birth preferences? (If not we can do this together) Yes No Have you shared your birth plan / preferences with your care provider? Yes No During early labour, when does your care provider want you to call them? Have you discussed protocols with your care provider if you go past your estimated due date? Please describe any activities you have been doing to physically/emotionally prepare for birth (eg. meditation, exercise etc) Have you packed a birth bag? (If no, we can do this together) Yes No What do you think will be your greatest challenge for this pregnancy / birth / postpartum experience? Do you have any persistent concerns / fears regarding your birth? What do you think will be your greatest strength for your pregnancy / birth / postpartum experience? In previously painful or emotionally intense situations (illness, injury, surgery) what have you found comforting? Please tick any pain management or relaxation techniques that you would NOT like to use. (Check those you DO NOT have interest in) Massage Meditation Directed breathing Visualization Rebozo Heating pads / hot packs Cold packs Music therapy Please list any other techniques you would like to try: Early Labour Preferences Continuous fetal monitoring Intermittent fetal monitoring No IV or heparin lock IV Vaginal checks limited to as few as possible Vaginal checks done per caregiver protocol Spontaneous rupture of membranes Do you want to be offered medications? (eg. Epidural) Medications not offered Epidural / narcotics Other Non-medical preferences Labour at home Labour in hospital Wear own clothes Fluids Ice / popsicles Food Aromatherapy Music Walking Shower / Bath Dim lighting Other General labour / birth preferences You chose your own birth positions HCP choses birth positons Pictures Video Perineal Massage Episiotomy Prefer to tear over episiotomy Cord cut by partner Cord cut by care provider Delay cord cutting Baby caught by partner with HCP help Announce the sex of baby Immediate skin-to-skin Baby cleaned before given to you Delay newborn procedures for one hour Placenta delivered without Pitocin Other If a hospital birth, please tick your immediate postpartum preferences: Bottle feed Give pacifier Waive eye ointment Waive vitamin K shot Waive PKU test Waive glucose test Waive Hepatitis B vaccine Circumcision In what ways do you hope a doula's support will be helpful to you? What types of assistance do you imagine will be most useful for you? How does your partner / support person want to be involved in your birth? Eg. Hands on, share support with doula, or let the doula take the lead? Please share anything else you would like me to know about you or any topics you would like to discuss. Photographic Release If you have let me know that you would like photography to document your labour and birth, and the situation allows it, I am happy to take pictures, and with your consent share them on my website and social media platforms. Please let me know your preferences below, or if you would like to discuss further. Yes I consent. You can use (non-explicit) pictures of me and my baby with my approval. No thank you. I am flattered but would like to keep the pictures private. Let's chat some more about this. Thank you! I’ll read over your answers and we will discuss more in depth at our first prenatal meeting. Don’t forget you can contact me anytime with any questions!
