Mothercare Intake Form I look forward to journeying together… Name * First Name Last Name Email * Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country What services are you interested in? * Prenatal Support Labour/Birth Support Postpartum Support Education/Consulting Virtual Support Due Date * MM DD YYYY Who is your care provider and what model of care do they offer? What are your main aspirations and desires for this birth? * Who are you planning to invite into the birth space with you? Describe the birth you are planning, preparing and dreaming of... Any pregnancy complications or concerns? Prior to your conception how were your cycles? If known, please add cycle length in days and regularity. If sensations/crams were severe, how did you deal with them? eg medication, heat, hydrotherapy, TENS, minerals, CBD ect.. Have you taken a child birth class? If so which one and what resonated Do you have any cultural, religious or theological consideration I should be aware of? What is/are your love languages to receive? Quality Time Acts of Service Receiving Gifts Touch Words of Affirmation Is there anything else you would like me to know? Previous birth experience section: What number birth is this for you? What were your previous birth experiences like? (home birth, undisturbed birth, physiological birth, induction, spontaneous labour, intervention, c-section, hospital, OBGYN, MGP ect...) Any experience of fetal or infant loss? Yes No Any pregnancy complications or concerns during a previous pregnancy? What comfort measures did you use during birth previously? Breath Hydro Therapy/Water Immersion Epidural TENS Massage Opioids Gas Relaxation Techniques Saline Injections Application of Heat or Ice Walking Movement Rocking Touch Therapy Hypnosis What comfort measures offered most relief and encouragement? When did your previous babies arrive? eg. 42 weeks + 5 What about your birth previous birth experience resonated and what did not? Thank you!
