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 InformationClient's Name *Client's Home PhoneClient's Cell Phone *Client's Email *Partner's Full Name *Partner's Phone *Planned Birth Location (Home/Hospital/Birthing Center) *Expected Due Date *Primary Care Provider *Do you plan to have anyone else present at the birth? If Yes, please list names. *Client's HistoryIs this your first pregnancy? *YesNoIf 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 DesiresWhat 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?Submit
