Client Intake Form


    Client Intake Form

    This form will give me some important logistical details, but will also tell me more about who you are and what you want for your birth. Everything that you enter here or discuss with me is completely confidential.

    Client Information

    Home Address (or location where you plan to labor)

    Do you plan to have anyone else present at the birth? If Yes, please list names.

    Client's History

    Is this your first pregnancy? YesNo

    If NO, how many pregnancies have you had?

    Where there any complications in any pregnancy? If YES, please describe.

    How many children do you have?

    Please share more about previous labor/birth experiences.

    Do you have any history of depression, anxiety, or trauma? If so, please describe.

    Birth Desires

    What is your vision for this birth? (Assuming there are no complications, please list the things that are important to you.)

    What is your partner's vision for this birth?

    Is there anything else you would like me to know?