CBE Intake Form

Her Village Birth Services

New Student Intake Form
Congratulations on your pregnancy! 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 NameLast Name
Your Partner's Name

First NameLast Name
Doctor/ Midwife's / Practice name*

First NameLast Name
Hospital for Delivery*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Home Phone*

Area CodePhone Number
Cellphone

Area CodePhone Number
Which class are you attending?
About Your Baby
Estimated Due Date*

MonthDayYear
BoyGirlUnknown
Baby's name (if known)
BreastfeedingFormula FeedingBothNot sure but would like more information
About Your Health
Please state your general health
Do you have any allergies I should be aware of?
Explain any complications you have had with this pregnancy, any restrictions your caregiver has given you, and any medications you are currently taking.*
Preparation for Birth
NoYes,Vaginally onlyYes, Cesarean onlyYes,Vaginally and Cesarean
Have you ever taken a childbirth education course before? If so, when and what style?
Please tell me what you most hope to get out of this class.
Labor pain management, coping skills, postpartum planning, etc
PartnerDoulaMother/ Mother-in-LawSisterFriendOther
Yes, It is a final copyYes, but it is a draft and would like some helpNo, I would like some help writing one.No, I have no interest in one.
What fears, concerns, questions do you have about labor and birth?
How do you feel about interventions in labor/delivery?
Comfort MeasuresIV MedicationEpiduralOther
DistractionsBreathing PatternsMassageBirth BallWalking, Dancing, SwayingWater (tub/Shower)Hot/Cold TherapyVisualization/ImageryFocal PointsAromatherapyMusic
What is your vision for this birth? *
What are your expectations of me as your childbirth educator?*
Any other questions or concerns?
Should be Empty:

Her Village Birth Services

About Your Baby

About Your Health