Client Onboarding Intake Form

Client Onboarding Intake Form

Please complete this intake form based on the client onboarding document. Preserve the original field order and answer all questions as provided.
Client & Contact Information
Name

First NameMiddle NameLast Name
Partner’s Name
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
E-mail
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Partner/Other Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Your Birth Date

MonthDayYear
Date
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship
Health Care Provider & Delivery Preferences
Health Care Provider Name
Type of Provider

Other
Health Care Provider Address
Health Care Provider Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Planned Delivery Location Type

Other
Name and Address of Delivery Location or Backup Hospital
Do You Have Health Insurance?
Health History
Allergies (list)
Recent illnesses, surgeries, injuries, accidents or trauma (describe)
Current medications/supplements (list and purpose)
Medical conditions (history/current)

Other
Psychological conditions (history/current)

Other
Other medical/psychological condition not listed above
Do you currently see a therapist or a counselor?
Additional health information
Obstetric History
Number of times you have given birth
Number of previous pregnancies carried to term (37+ weeks)
Number of previous preterm pregnancies (24–37 weeks)
Number of children; names and ages
Have you given birth to multiples?
Types of births experienced

Other
Duration of previous labor(s)
Past pregnancy-related health conditions

Other
Notes about past pregnancies
Current Pregnancy Details
Baby’s Due Date

MonthDayYear
Date
Expecting multiples?
Baby’s gender
Baby’s name (if chosen)
Do you plan to share the name with others?
Childbirth education classes (type and location)
Hoped-for type of birth
Planned pain management approach
Current pregnancy-related health conditions

Other
Other current conditions not listed
Birth Plan, Support & Postpartum Preferences
Do you have a birth plan or vision?
Three most important desired outcomes for this birth
Envisioned role for me at your birth
Who will be with you at the birth and their roles
People you do not want present at birth or immediate postpartum
How can I help your partner be more supportive during labor?
Difficulties, complications, or restrictions during this pregnancy
Fears about this birth
Preferred comfort measures during labor

Other
Other comfort techniques you would like to use
Are you planning on breastfeeding your baby?
Topics to focus on during prenatal visits or conversations
Comments or questions about anything
Should be Empty:

Client Onboarding Intake Form

Client & Contact Information

Health Care Provider & Delivery Preferences

Health History

Obstetric History

Current Pregnancy Details

Birth Plan, Support & Postpartum Preferences