Name
*
First Name
Last Name
Phone
*
(###)
###
####
Email
*
Spouse, Partner, or Support Person's Name
First Name
Last Name
Relation to Client
Spouse/Partner/Support Person's Phone
(###)
###
####
Estimated Due Date
*
MM
DD
YYYY
I am expecting
*
Do you know your baby (or babies) gender?
*
Care Provider
*
Name of Practice and name of OBGYN or Midwife
*
Birth Location
*
Birth Location Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
If you are planning a home birth, incase of needing to be transferred, which hospital would you be transferred to?
Are you planning on having a Doula?
Name of your Doula
Doula's phone number
(###)
###
####
Do you plan to use a birth pool?
*
Is this your first birth?
*
Past Labors, please check all that apply
*
Is there anything else you'd like to tell me about your past birth experiences?
If your older child(ren) will be present at your birth, can you tell me their names and ages and if you have any special plans to include them? For example, for them to cut the cord, etc...
*
Is there anyone else that you plan on having in attendance at your birth? Parents, grandparents, family members, a friend? If so, can you tell me about them?
Is there anything else you'd like me to know about your birth plan or birth space?
How has your pregnancy been so far? How are you feeling, emotionally and physically?
I strive to capture your entire birth story; your space, the love with your partner/support person, the connection with your birth team, the hard moments, your strength, the powerful moments, the quieter moments, all the beauty that is birth. Is there anything specific that you are hoping for me to capture? Is there anything that you'd like me to avoid? Are you comfortable with crowning photos? - a reminder that these photos are for you and I only share photos to my website/social media that you have approved.
