Lactation Support Intake Form

Lactation Support Intake Form

Please complete this intake form to help me understand your needs and provide personalized lactation support.
Mother’s Full Name

First NameLast Name
Email Address
example@example.com
Phone Number (Optional but recommended)
Please enter a valid phone number.Format: (000) 000-0000.
Baby’s Age or Estimated Due Date
What is your primary concern right now? (Select all that apply)

Other
Are you currently:
Did your baby have any of the following? (Select all that apply)
How would you describe your birth experience?
What kind of support are you looking for?
Is there anything else you want me to know before we connect?
I understand that the personal and health information I share with Aarica McClary will be kept confidential and used only to provide lactation support services. My information will not be shared with third parties except as required by law or with my explicit written permission. I understand that virtual consultations (phone, video, or messaging) carry inherent privacy limitations related to technology platforms and I consent to receiving services through these methods. For urgent medical concerns, I will contact my healthcare provider or emergency services directly rather than waiting for a response.
I understand that Aarica McClary is a breastfeeding counselor who is actively accumulating supervised clinical hours toward the International Board Certified Lactation Consultant (IBCLC) examination. I understand that Aarica McClary is not a licensed medical provider and that the support provided is not a substitute for medical advice, diagnosis, or treatment from my physician, midwife, pediatrician, or other licensed healthcare provider.I understand that my case may be discussed with a supervising, credentialed IBCLC for educational oversight and quality of care purposes. All such discussions will maintain my confidentiality to the extent possible. I agree to seek medical attention promptly if I or my baby have any urgent health concerns and will not rely solely on lactation support for medical decisions.
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Lactation Support Intake Form

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