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Midwives Questionare 
This is a live form and may change from time to time.
Please complete this form to the best of your ability- I don't expect you to know all the answers at this time. These questions provide me with information while also encouraging you to give thought to those you are unsure of
The purpose of this form is to begin to explore how we may work together. Answers will not preclude you from joining this practice, rather give an idea of where you are and how I can best show up for you.
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Email *
What are your names? 
How did you find me?
Where do you feel you fall on the emotional/spiritual scale? *
I am not in a place where I can put energy into this work.
I have been, and continue to sink deeper into myself.
How might you describe your significant other in relation to the above queue? *
What brought you to home birth? *
Would you like to share your vision of what your relationship with midwifery may look like? *
Do you feel supported by the important people in your life to birth at home? *
If not, are you able to release any need for their approval? *
If you have children, how do you envision their involvement?
Have you been pregnant/given birth in the past? How was this experience for you? *
For your significant other? *
I have experienced the following *
Are you currently pregnant? *
Please share the guess date you have been using and how this date was chosen.
To the best of your knowledge are you experiencing a low risk pregnancy? *
Briefly share thoughts you have regarding the larger decisions that come with parenting- (e.g, vaccines, circumcision, nursing/extended nursing, co-sleeping etc) *
What is your view in regards to the current systems in place? e.g medical, insurance, governmental agencies. *
I eschew these systems and would prefer not to participate in them where possible.
These systems are fine, no change needed.
The investment in a concierge midwifery relationship is $5500. Are you able to help create and commit to a payment schedule? *
Are you located within 90 minutes of Brownfield Maine? What town are you located? *
Are you able to be flexible with scheduling? *
Would you like to receive my FAQ & financial documents? If yes, please share preferred email. *
Thank you for taking the time to complete this form.  Once I have reviewed all that has been shared, I will follow up with you via above email.
Midwife Gayle 
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