Consultation Intake Form

I am excited for the opportunity to serve you and your growing family through your scheduled consultation!

Please complete the form below as thoroughly as you can, with the understanding your thoughtful responses are used to help me prepare to meet your specific needs and birth goals. As with all personal information you share with me, the information collected in this form will be kept confidential.

Name

First Name

Last Name

Phone

(###)

###

####

Your date of birth

YYYY

Partner's name

First Name

Last Name

Relationship to partner

Estimated due date

YYYY

Place of birth

Care provider

Child's gender

Boy

Girl

Plan to find out but haven't yet

Birth-day surprise

How would you describe your pregnancy so far? Have you experienced any complications with this pregnancy?

Describe what encouraged you to seek counsel from me? What aspects of labor or topics specific to your birth do you desire to discuss in more detail during your consultation?

What type of birth do you desire to have? What do you envision for it?

Briefly describe your previous birth(s), if applicable.

What aspect of birth are you currently the most confident about?

Is there an aspect of labor that you have found yourself thinking about or worrying about more than others?

Have you been labeled high-risk by your care provider? If so, please briefly describe why?

Do you have any pre-existing medical conditions that may affect your pregnancy/birth/postpartum?

Are you planning to or currently taking a childbirth or breastfeeding class? If so, which one(s)?

How did you learn about my services?

If there is anything about you, your partner or pregnancy, upcoming birth or child that you feel would be helpful for me to know, please share that here.

CONSUTATION DETAILS

By checking the box below, I acknowledge that the consultation length is 90 minutes and the fee is $150. I agree to pay this fee via Venmo to @ldbirthservices prior to my scheduled consultation.

I understand and agree

I do not agree

WAIVER

By checking the box below, I acknowledge that the content discussed within my consultation is for informational and educational purposes only. It is not intended for individual medical advice, and does not take the place of medical advice or treatment from a physician. I understand I should consult my own doctor or qualified healthcare professional for specific health concerns and questions.

I understand and agree

I do not agree