Pregnant & Breastfeeding Mom Intake Form

Durham's Maternal Stress Free Zone Pregnant and Breastfeeding Mother Program

New Client Intake Form
To qualify for the Program, you must:

*Currently be pregnant

*Thinking about or planning to breastfeed

* Currently breastfeeding

* Live within the city of Buffalo.

Thank you for taking the time to fill out this form so I can get to know you better and have an idea of how I can best support you during your pregnancy, birth and postpartum!
Your Name *

First Name Middle Name Last Name
Your Partner's Name

First Name Last Name
Hospital for Delivery *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail
Home Phone *

Area Code Phone Number
Cellphone

Area Code Phone Number
About you and your baby
Your date of Birth *

Month Day Year
Baby's Birthday or Estimated Due Date *

Month Day Year
Baby's Gender

Boy Girl Unknown
Baby's name (if known)
Planned Method of Feeding *

Currently Breastfeeding Plan to Breastfeed Not sure but would like more information
Birth and Breastfeeding Goal Questions
Have you given birth before? *

No Yes,Vaginally only Yes, Cesarean only Yes,Vaginally and Cesarean Did you Breastfeed any of your other children (if applicable)
What are your Breastfeeding Goals
The AAP recommends exclusive breastfeeding for about 6 months, with continuation of breastfeeding for 1 year or longer
How did you hear about us/who referred you to our program? *
Should be Empty:

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Durham's Maternal Stress Free Zone Pregnant and Breastfeeding Mother Program