Client Intake FormIn order to make our journey a smooth one, please fill out this intake form to the best of your ability. In the event that we are not a fit for each other, I guarantee that I will discard this form. Contact Information Pregnant Person's Name * First Name Last Name Pronouns * Pregnant Person's Email * Pregnant Person's Phone * (###) ### #### Partner/Support Person's Name First Name Last Name Partner/Support Person's Email Emergency Contact (Name, Phone Number, Relationship) Birthing Information Estimated Due Date MM DD YYYY Medical Care Provider Birthing Location (Hospital, Home, Birthing Center, etc) Birthing Location Address Address 1 Address 2 City State/Province Zip/Postal Code Country If birthing outside your home, have you visited your birthing location for a tour? Yes No I plan on it Questions About You and Your Pregnancy Does the pregnant person have any allergies? Food/Medication List any medical conditions prior to pregnancy that may affect pregnancy or birth: Select any medical conditions developed during pregnancy: None Anemia Anxiety/Depression Back Pain/Injury Fetal Problems Gestational Diabetes Group B Strep Hyperemesis Gravidarum (severe morning sickness) Infections Preeclampsia Placenta Previa Placental Abruption Other: Please describe your sleeping habits during your pregnancy: What number pregnancy is this for you? Number of previous births? Education & Resources Have you taken or plan on taking any childbirth education classes? Please list date and location if applicable Are you and/or your partner/support person reading any books about childbirth, pregnancy, breastfeeding, etc? If so, please list the books. List any questions or topics about pregnancy and birth you want to discuss further: Birth & Postpartum How do you envision your birth? Describe what your perfect birth looks and feels like. Do you have a birth plan? If not, we can work together to create a birth plan. Is your medical provider aware of your birth plan/preferences? During early labor, when does your medical provider want you to call them? If you go past your estimated due date, do you and your medical provider have protocols in place? Have you packed a birth bag? If not, we can pack one together. Non-Medical Birth Preferences Labor at home Labor in hospital Music Aromatherapy Spiritual tools of choice (sage, crystals, incense, etc) Walking Bathtub/Jacuzzi/Pool/Shower Dim lighting Ice/Popsicles Fluids Food Birth ball Other: Birth/Labor Preferences Health Care Provider chooses positions Birthing person chooses positions Perineal Massage Episiotomy Prefer to tear over an episiotomy Delay cord clamping/cutting Partner cuts cord Health care provider cuts cord Baby caught by partner or birthing parent if possible Baby immediately placed on birthing parent Baby cleaned before being placed on birthing parent Newborn procedures delayed for 1 hour No pain medication unless requested Placenta delivered spontaneously without assistance Do not discard placenta Do not announce baby's gender Other: Early Labor Preferences: Continuous Fetal Monitoring Intermittent Fetal Monitoring No IV or Heparin Lock IV Vaginal checks limited to as few as possible Vaginal checks done per HCP/Staff Protocol Spontaneous rupture of membrane Medications offered (i.e. epidural) Medications not offered Epidural/narcotics Other: If a hospital birth, please check your immediate postpartum preferences Bottle feed Give Pacifier Waive eye ointment Waive Vitamin K shot Waive PKU test Waive Glucose test Waive Hepatitis B vaccine Circumcision (with anesthesia) Who is in your postpartum support team? Check all that apply Partner Family Friends Postpartum Doula Lactation Consultant No-one Please select any pain management/relaxation/grounding techniques you WOULD NOT like to use: Massage Acupressure points Aromatherapy Meditation Directed breathing Visualization Rebozo Heating pad/hot packs Cold packs Music therapy Herbal Support Reiki Please list any pain management/relaxation/grounding techniques you WOULD like to try: Do you have a postpartum plan? Additional Questions What activities have you been doing to prepare for your birth? Please describe any physical or emotional activities, ie. journaling, meditating, yoga, etc. Do you have any persistent fears or concerns regarding your birth? During situations of intense pain or emotion, what do you find most comforting and/or grounding? What strengths do you think will help you through your pregnancy, birth and postpartum journey? What do you think will be most challenging about your pregnancy, birth and/or postpartum journey? What support do you feel would be most helpful from your doula? How does your partner want to be involved in your pregnancy/birth? hands on? share support? allow doula to take the lead? Please describe your mental, emotional, and physical experience during this pregnancy so far: Please list anything else you want to share, discuss, or think I should know: Photographic Release * If you consent, I will use non-explicit photos, approved by you, of your birth and pregnancy on Inaru Wellness's social accounts and websites. You will also be provided with a photo release document to sign when we meet in person. Yes, you may use non-explicit photos, approved by me, of my birth and pregnancy for your social accounts and website. No, you may not use any pictures. Can we please discuss this further? Thank you!
