Getting to Know You

Please complete this form once you’ve established care with us. It will help us know more about who you are and the support you are looking for in advance of our in person meetings. All answers are optional. The more we know about you the better we can support you.

Name of Pregnant Parent

First Name

Last Name

Midwife or OB Name/ Practice Name

Baby's Sex

Baby's Name if Known and Sharing

Planned Method of Feeding Baby

Plans for Your Placenta

What health conditions would you like us to be aware of?

What allergies or sensitivities should we be aware of?

Please explain any complications or concerns with your pregnancy and any restrictions your caregiver has given you that we should be aware of

Please describe what classes or other learning you've done to prepare for this birth, including name of childbirth education class

Who do you plan to have with you besides you care provider and doula to provide support at your birth?

What referrals are you interested in at this time (may include childbirth education, massage therapy, chiropractor, midwife, mental health therapist, etc. etc.)

(Apple Health only) please provide your Date of Birth for Eligibility Verification

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