Lactation Intake

Intake Form and Terms and Conditions for Lactation Services

Please complete the questions as best you can. If you forget to add something, no worries, you can always add additional information by emailing me.

Breastfeeding Parent Name*

First NameLast Name

Date of Birth*

Date

Partner's Name

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

E-mail*

example@example.com

Baby's Name:*

Baby's Date of Birth / weeks of gestation *

Referred by? *

Birth weight?*

Discharge/lowest weight and date?*

Last weight and date? *

Pediatrician and Practice Name, Include Fax Number *

Midwife/OB Name and Practice, Place of Birth *

Baby is child number*

123 or more

Type of birth*

If you have breastfed previously, please describe. *

In your own words describe challenges you are having and goals you hope to reach.*

Taking any medications or vitamins currently?*

YesNo

If yes, please list:*

Medical Conditions?*

Any difficulty getting pregnant or infertility issues? Describe.*

Breast Changes During Pregnancy?*

LargerDarkerNone

How often has baby nursed in last 24 hours?*

Full milk in on?*

One day3-4 daysOther

Engorged?*

EngorgedNo engorgement

Pees and Poops? Number and color in last 24 hours? Color?*

One or Both Breasts per Feeding?*

Latching Difficult?*

YesNoSometimes

Painful to nurse?*

Are you pumping? When? Which pump? Amount expressed at a session?*

Using pacifier? If so, when?*

Returning to work?*

YesNo

Age of baby when you return to work?

Occupation?

Please provide in detail, any additional information that will help me understand what's going on. If you have specific questions you can include them here too.

If you forget to add something, no worries, you can always add additional information by emailing me.

How did you hear about Graceful Beginnings? *

TERMS AND CONDITIONS

I give my consent for the lactation counselor to work with me and my baby during this consultation for my breastfeeding problem/concern. This consent is for visits, phone conversations, and information sent by e-mail, fax or text, and includes appropriate follow-up contacts. I understand that a lactation consultation may involve: touching my breasts and/or nipples for the purposes of assessment; inserting gloved fingers into my baby's mouth to assess suck; observation of a breastfeeding, and suggestions to enhance latch or position; demonstration of the use of equipment or supplies that may be recommended, and demonstration of techniques designed to improve breastfeeding. I understand that I am responsible for informing the lactation counselor of changes I feel are necessary in the care path at the time of the visit or during the course of follow-up communications. I understand it is my responsibility to advise the lactation counselor with progress reports, questions or concerns. I give my consent for the lactation counselor to release any information acquired in the evaluation and/or management of myself and/or my child to our health care providers, referring physician, and/or our insurance company upon request. I am not, nor am I holding myself out to be a doctor/physician, nurse, physician’s assistant, advanced practice nurse, psychiatrist, psychologist, therapist, counselor, or social worker (“Mental Health Provider”), registered dietician or licensed nutritionist, or member of the clergy. As a Certified Lactation Counselor, I provide knowledge and counseling about optimal and sub-optimal breastfeeding. I am not providing health care, medical or nutritional therapy services, or attempting to diagnose, treat, prevent or cure any physical, mental or emotional issue, disease or condition. You agree and acknowledge that I am not providing medical advice, mental health advice, or religious advice in any way. Always seek the advice of your own Medical Provider and/or Mental Health Provider regarding any questions or concerns you have about your specific health or any medications, herbs or supplements you are currently taking. Do not start or stop taking any medications without speaking to your own Medical Provider or Mental Health Provider. If you have or suspect that you have a medical or mental health problem, contact your own Medical Provider or Mental Health Provider promptly.

I understand total payment is expected at the conclusion of the consultation. Additionally, please be aware that our lactation counselor tailors her response to your specific situation, taking into account the information you have shared. Our response may not be appropriate for other mothers, since each mother and baby couple is unique and should not be shared.

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