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The matriwoumb Sanctuary
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Your Birth Partners Name
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Albania
Algeria
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Andorra
Angola
Anguilla
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Armenia
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Chile
China
Christmas Island
Cocos (Keeling) Islands
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Congo
Cook Islands
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Cote d'Ivoire
Croatia
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Curaçao
Cyprus
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Democratic Republic of the Congo
Denmark
Djibouti
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Dominican Republic
Ecuador
Egypt
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Equatorial Guinea
Eritrea
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Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
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Japan
Jersey
Jordan
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Kiribati
North Korea
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Kuwait
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Mali
Malta
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Norfolk Island
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Saint Lucia
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Samoa
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eSwatini
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6
Your Email
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example@example.com
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7
Are you a travel client?
Our home base is Georgia anyone outside of GA is considered a travel client
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NO
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8
How many weeks pregnant are you?
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9
Estimate Due Date
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If you're not expecting select todays date and answer next question.
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Date
Month
Day
Year
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10
Im not expecting, I'm interested in:
Pre Prepped Meal Plan
Nutritionist Plan
Spiritual Guidance
Pre Prepped Meal Plan
Nutritionist Plan
Spiritual Guidance
Plans
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11
Doctor/ Midwife's / Practice name
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12
Delivery Location
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Home, Birth Center, Hospital
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13
Planned Method Of Feeding
Breastfeeding
Formula Feeding
Combination
Not sure but I would like more information
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14
Are you currently experiencing any specific health or other concerns that affect this pregnancy? As with all of your information, anything you share will be kept confidential.
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Explain any complications you have had with this pregnancy or any restrictions your caregiver has given you.
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15
Have you given birth before?
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No
Yes, Vaginally only
Yes, Cesarean Only
Yes, Vaginally and Cesarean
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16
Any history of miscarriage or infant loss?
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No
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No
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17
How do you see the roll of a doula? What does doula support look like to you?
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18
Have you taken or are you planning on taking any childbirth education classes?
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Ex: Breastfeeding, Infant Care, Infant CPR, Sibling Classes, Prenatal Yoga
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19
Do you have a birth vision planned?
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Yes, it is a final copy.
Yes, but it is a draft and I would like some help.
No, I would like like help writing one.
No, I have no interest in one.
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20
How do you feel about interventions in labor/delivery? How would you like your doula to respond if you are requesting pain medication?
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21
What type of pain management are you looking to use?
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Comfort Measures
IV Medication
Epidural
Other
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22
What is your vision for this birth?
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Top 3 Most Important Points
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23
During labor and birth, emotions associated with prior sexual abuse can come to the surface. As your support, it can be helpful for me to be aware if this issue exists ans what your triggers are or may be. As with all of your information, anything shared will be kept confidential
Do you have anything to share that may help me avoid any triggers you may have?
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24
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25
What type of comfort measures would you like to use in labor?
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Choose all that apply
Distractions
Breathing Patterns
Hypnosis
Mediation
Massage
Birth Ball
Walking, Dancing, Swaying
Water (Tub/Shower)
Hot/Cold Therapy
Visualizations/Imagery
Focal Points
Aromatherapy (Essential Oils)
Music
Sound Bowl Healer
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26
Additional Services
If you would like to add or inquire more information please select
Postpartum Ceremony
Wellness Care 16w, 20w, 24w, 26w, 32w, 36w
Spiritual Guidance
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27
Would you like to request our male doula for extra support/ partner support?
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YES
NO
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