New Client Intake Form

New Client Intake Form

Congratulations on this new journey! Let us know a little more about what you are looking for and how we can help you.
Before you move forward, we want to be transparent about our payment options. While we currently do not bill insurances directly, we offer these options to help:
- Payment Plan: Flexible payment plans to suit your needs.
  - (we have more detailed information on our pricing sheet that we can send out via email)
- HSA/FSA: We accept Health Savings Accounts (HSA) and Flexible Spending Accounts (FSA).
- Afterpay: Convenient installment payments through Afterpay.
- Superbill for Insurance Reimbursement: We can provide a superbill for you to submit to your insurance for reimbursement.
- Carrot Insurance: We accept Carrot Insurance through their reimbursement and attestation forms.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Partner's/Spouse's Name (if applicable)

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Any pets in the home? If so, please specify.
Estimated due date or baby's date of birth.*

MonthDayYear
Date
Check all that you are interested in.*

Birth SupportDaytime Postpartum (8am-8pm)Overnight Postpartum (8pm-8am)Lactation SessionHolistic Fertility SupportPlacenta EncapsulationPartner Guidance SessionTrauma & Emotional Healing Through Guided MeditationChildbirth ClassesNewborn Care Informative Classes
If you selected birth support, where is your planned place of birth?

HospitalHomeBirth CenterUnsure, would like some guidance.
If you selected postpartum support, approximately how many weeks/months are you thinking you will need support for?
Is there anything specific you are looking for information on?
Specify your concerns, be as detailed as possible so we know which areas to focus our support on.
Do you have any history of anxiety/depression?

YesNoNot sure
Any important information you would like to share with us, that you think would affect your journey?
We offer emotional and educational guidance and can help through any fears or concerns that can come up for you.
Do you have any specific questions for us that we can go over during the intake consult call.
How did you hear about us?
Please share their name and email if you are able to so we can send a thank you!
Schedule an Intake video or phone call
Should be Empty: