Client Intake FormThank you for taking the time to fill this out! This form will be used to get to know you better so I can tailor your support to YOU! Name * (Name that your birthing location would identify you as) First Name Last Name Preferred Name First Name Last Name Email * Phone * (###) ### #### Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Partner's Name * (Or Primary Support Person) First Name Last Name Partner's Phone * (###) ### #### Partner's Email * Birth Location Doctor/Midwife's Name, Hospital Name, City, State Due Date * MM DD YYYY Baby's Gender Boy Girl Surprise Baby's Name (if known) Planned Feeding Method * May select multiple choices Formula Breastfeed/Chestfeed Pumped Breastmilk Not sure yet, would love more info Client's General Health * Have you been diagnosed with any health issues prior to or during your pregnancy? Please list them here, as well as any other health concerns I should know about. Client's Allergies * Medications, food, atmospheric, essential oils, etc. Client's Current Medications * Include vitamins, over the counter, and prescribed Number of Pregnancies * (including current pregnancy) Number of Live Births * Please list any other classes you are attending for this pregnancy (Lactation classes, postpartum, newborn, CPR/First Aid, etc.) Who do you plan to be present during your labor and birth? * What are your primary labor and birth goals? * (Other than baby and mom being safe and healthy!) I am excited for... * I am nervous for... * What pregnancy/birth/postpartum customs, rituals, and traditions do you have that I should know about? Photo/Video * Would you like to allow photography or video recordings during your labor? Photographs Video recordings Avoid nipples showing Avoid genitalia showing Will be hiring a professional photographer/videographer No photos or videos, please! Social Media Release * Doula may share the following information on social media platforms (website, Instagram, Facebook). All information will be verified before being posted. If agreeing for photos to be shared, you will not be tagged and they will be non-identifying unless verified explicitly by yourself. Photographs Video clips Must be non-identifying (e.g. no faces) No photos/no videos/non-identifying posts but you may say "Baby arrived!" or "Baby on the way!" No posts of any manner Would you be open to a shadow Doula? * This would be a trained set of second hands, usually someone who has attended births but needs more in-person experience. You would meet them before your birth during a prenatal visit. Yes No What are your expectations of me? * How did you hear about Sway Into Birth? * Any questions, concerns, or other information you feel is important to know as your Doula? Thank you! I am looking forward to working with you!-Katherynn
