Birth Keeper Support
Congratulations on your new pregnancy! 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 please take the time to fill out this form.
Your Name
*
First Name
Last Name
Your Phone Number
*
-
Area Code
Phone Number
Birthdate
*
-
Day
-
Month
Year
Date
Your Birth Partner's Name
First Name
Last Name
Your Birth Partner's Phone Number
-
Area Code
Phone Number
Your Home Address
*
Street
House Number
City
State / Province
Postal / Zip Code
Your Email
*
example@example.com
Your Birth Partner's Email
example@example.com
Current Pregnancy Information
Estimate Due Date
*
-
Day
-
Month
Year
Date
Do you have a Dr or Midwife?
*
Yes
No
Other
Doctor/ Midwife's / Practice name
Birth Location
*
Unassisted Free Birth
Assisted Home Birth
Birth Centre
Hospital
I'm not sure yet.
Other
Address of birthing location if known:
Planned Method Of Feeding
Breastfeeding
Formula Feeding
Combination
Not sure, I would like more information
Do you have any specific health or other concerns that you feel are affecting this pregnancy?
*
Do you feel you have any complications or restrictions with this pregnancy.
*
Do you have any unsure thoughts or fears around pregnancy, birth, postpartum and motherhood?
*
Pregnancy History
Have you given birth before?
*
No
Yes, Vaginally only
Yes, Cesarean Only
Yes, Vaginally and Cesarean
What have your previous labour and births been like?
*
Do you have a history of miscarriage or infant loss?
Yes
No
Did you experience any birth trauma?
*
Yes
No
Not sure
Please share any birth trauma details if you feel comfortable.
*
Birth Preparation
What does birthing Unassisted / Free Birth mean to you?
*
Why do you want to birth Unassisted / Free Birth?
*
Have you taken or are you planning on taking any childbirth education classes?
*
Are you interested in childbirth classes?
*
Yes
No
Not sure
What where you hoping to get from these classes? Were your expectations met?
Who do you plan to have support you with your labor?
*
Photographer
Birth Keeper
Mother/Mother-In-Law
Partner/Spouse
Aunty/Sister
Friend
Other
Have you written a birth plan?
*
Yes, it is a final copy.
Yes, but it is a draft and I would like some help.
No, I would like help writing one.
No, I have no interest in one.
How do you imagine your birth to be like? Location, support, interventions, etc.
In 5 words, please describe how you would like to FEEL and how you would like your birthing space to feel? (ex: calm, peaceful, energised, happy)
Are there any cultural/religious preferences for your birth that I should know about?
How do you feel about medical/natural interventions in labor, birth and postpartum?
What type of comfort measures would you like to use in labor?
*
Distractions
Breathing Patterns
Massage
Birth Ball
Walking, Dancing, Swaying
Water (Tub/Shower)
Hot/Cold Therapy
Visualizations/Imagery
Hypnobirthing
Focal Points
Aromatherapy (Essential Oils)
Music
Birthing Comb
TENS
No sure yet.
Other
Are you interested in any other services I provide? - All services are listed and priced on the webiste.
*
Birth Photography
Maternity Photoshoot
Fresh 48 Photoshoot
Postpartum Supprt
Birth Pool Hire
Massage
Belly Casting
Other
Where did you find 'Shapirah'?
*
What draws you to have a Birth Keeper present? What type of support do you imagine a Birth Keeper having for your birth?
*
Is there anything else that you would like to share with me?
*
Thank you so much for trusting me to be apart of your pregnacy and birth space!
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