1 on 1 Consult Intake
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 1 on 1 session, 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 Home Address
*
Street
House Number
City
State / Province
Postal / Zip Code
Your Email
*
example@example.com
Current Pregnancy Information
Estimate Due Date
*
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Day
-
Month
Year
Date
Do you have a Dr or Midwife?
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Yes
No
Other
Doctor/ Midwife's / Practice name
Delivery Location
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Home Unassisted
Home Assisted
Birth Canter
Hospital
I'm not sure yet.
Other
Planned Method Of Feeding
Breastfeeding
Formula Feeding
Combination
Not sure, I would like more information
Are you currently experiencing any specific health or other concerns that affect this pregnancy?
*
Explain any complications or restrictions you have had with this pregnancy.
*
Do you have any unsure thoughts or fears around pregnancy, birth, postpartum and motherhood?
*
Pregnancy History
Have you given birth before?
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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?
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Yes
No
Not sure
Please share any birth trauma details.
*
Consult Information
What support or information are you looking for from this consult?
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What are your main pregnancy, birth and pp questions?
*
Where did you find 'Shaphirah'?
*
Is there anything else that you want to share with me?
*
Thank you so much for trusting me to be apart of your pregnacy and birth space!
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