Client Alignment Questionnaire

Client Alignment Questionnaire

Your time, honesty, and reflections are deeply valued. Because I intentionally work with a select number of families, I prioritize those who are ready to invest in the deep inner work and preparation that homebirth midwifery requires, and who embrace the understanding that birth is both powerful and unpredictable. After reviewing your answers, I’ll be in touch with next steps regarding the consultation process.
Full Name*

First NameMiddle NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Birth*
Date of the first day of your last menstrual cycle

MonthDayYear
Date
Have you experienced a homebirth before? If yes, please share what you loved about the experience and what you might choose differently next time. If not, what draws you to homebirth midwifery care, and what feels most important to you about this choice?*
How do you view your role vs. your midwife’s role during pregnancy and birth? What values do you hope your provider embodies?*
What are your expectations of your midwife, especially around communication and decision-making? How do you prefer to handle differences in opinion about care decisions?*
What does “taking responsibility for your care” look like to you? Are you willing to make adjustments (nutrition, movement, emotional preparation, etc.) to support your pregnancy, birth, and postpartum?*
How would you feel if your birth plan or location needed to change (for example, transfer to a hospital)? Do you understand that no outcome can be guaranteed?*
Who are the key people supporting you in pregnancy and birth, and how do they feel about homebirth? What does your ideal birth support team look like?*
Please share any medical conditions, prior pregnancy complications, or other factors that may be important for your midwifery care.*
Please share a little about your home environment. Do you feel it is a safe, clean, and supportive space for birth (for example, reliable electricity, running water, a generally tidy area for the birth team to set up, and easy access for emergency services if ever needed)?*
Thank you for sharing your responses and taking the time to complete this form. I’ll review your information and be in touch soon with next steps about a consultation. I appreciate your openness and look forward to connecting with you.

- Jen
Should be Empty: