Home Address

Email

Mother's age at time of birth

(in years)

HEALTH INFORMATION

Please answer these questions to the extent you feel comfortable. Although I’m not supporting you from a medical point of view, it would be really helpful if I am able to understand you and your health so that I may support you in the best way possible. You may not be able to answer some of these questions and that is totally okay too. We are going to work together closely so I can help you fill in any gaps to make the best choices for your individual situation.

Do you have any allergies? (if yes, please explain)

Are there any foods that you or your partner don’t eat? (I am likely to bring snacks for the labour and post birth, and don’t want to bring something you or your partner don’t like)

Have you had any recent illnesses, surgeries, injuries. accidents or trauma that I should know about so I can support you better? (if yes, please describe)

Do you currently have, or do you have a history of, any medical or psychological conditions that I should be aware of?

How many children do you have? Please list name(s) and age(s)

Please tell me anything you would like me to know about your previous birth experience(s)

Have you had any pregnancy-related health conditions in your CURRENT pregnancy? Please tell me anything you would like me to know about this pregnancy

Describe your ideal birth. How do you envision it?

What would you say are the three top character strengths that you possess?

Eg. Resilient, flexible, loyal etc.

Please describe what you think it would look like to be "mentally strong" or have a "positive mindset" for birth?

This is not a test! I just want to know (in your words) what this means to you

Please describe the role you envision for me at your birth

This can be physical, emotional, mental or spiritual support

Who else will be with you at the birth, and what role would you like them to play?

This is for extra support people other than your birth partner and myself. Eg. Your sister, mum, friend etc.

How can I support your birth partner to help them be more supportive to you during labour and birth?

Have you had any difficulties/complications/restrictions (physical, emotional, or other) with and during this pregnancy?

Do you have any strong concerns or fears around this birth? If easier, we can discuss these in person.

How do you feel about medical procedures and interventions during labour and birth?

I'll always ask for your consent before making any physical contact and will remain mindful of your personal boundaries. Are there any specific areas you prefer not to be touched? Eg. Ticklish feet.

In the event of an unexpected caesarean section, what can I do to support you? (what would be most important/helpful)

Are you planning on breast feeding your baby?

If you have previous breast feeding experience, please tell me anything you would like me to know

Are there any particular topics that you would like to focus on during our prenatal visit(s)/conversations?

Comments/questions about absolutely anything!

ALMOST FINISHED!

Please rate your confidence/comfort or readiness for each of the following topics with a number ranging from 1-10. Closer to 10 means you feel confident/comfortable/ready Closer to 1 means you'd like to talk through this topic more and have more support in this area.

Baby's Health

Your health + pregnancy discomforts

Your body image

Current lifestyle changes: career, home, nutrition + exercise

Family relationships: your family of origin and baby's siblings

Relationship with Birth Partner

Relationship with Medical Care Providers

Hospital, midwife, GP, Obstetrician etc

Your Birth Support Team

Your birth partner, doula, and anyone else who you have specifically invited into the birth space

Coping With Labour

Knowledge + ability to advocate for yourself

Feeling clarity around your birth plan, vision, desires, wishes for birth

Basically do you know what you want?

Postpartum period: recovery, baby care + breastfeeding

Thanks so much, you did it.

Client Intake Form