Client Intake Form

First Name

Last Name

Home Address

Birthing Mother's Phone Number

Birth Partner's Name & Phone Number

Estimated Due Date of Baby

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.

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)

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)

If you are vaginally birthing, how do you plan to birth?

Naturally (comfort measures/no pain medication)

Epidural

Other pain medication

Have you had any pregnancy-related health conditions, illnesses, surgeries, injuries, accidents or trauma in your CURRENT pregnancy? Please tell me anything you would like me to know about this pregnancy

BIRTH DESIRES: Do you have a birth vision?

Yes

Need help

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?

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?

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

Client Intake Form

Thanks so much, yess!!! I know it was a lot, but it's really going to help me support you better 🤎

◇ Together We Birth ◇ Bonnie Walker ◇

Professionally Trained Birth Doula • Fully Accredited Transformational Birth Coach • Childbirth Educator
• Online Birth Classes • Virtual Doula Services

Continuously supporting families ~ emotionally, physically & practically ~ for a positive birth experience

Email Me Phone Me

Join Our Free Trial

Client Intake Form

Thanks so much, yess!!! I know it was a lot, but it's really going to help me support you better 🤎

◇ Together We Birth ◇ Bonnie Walker ◇

Professionally Trained Birth Doula • Fully Accredited Transformational Birth Coach • Childbirth Educator • Online Birth Classes • Virtual Doula Services

Continuously supporting families ~ emotionally, physically & practically ~ for a positive birth experience

Email Me Phone Me

Join Our Free Trial

Professionally Trained Birth Doula • Fully Accredited Transformational Birth Coach • Childbirth Educator
• Online Birth Classes • Virtual Doula Services