Consultation Questionnaire
Please fill out this form in full so that I am best able to determine if we can move forward with a consultation.  You'll get a text message from (979)349-9565, so feel free to add me to your contacts.  Thank you and I look forward to chatting with you!
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Email *
Please provide your phone number (this will be used to contact you to schedule your consult) *
What is your full name? *
What city do you live in? *
What was the first day of your last menstrual period? *
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Are you interested in homebirth or planned hospital birth? *
Have you had any previous surgeries? If so, please indicate the type of surgery and the date/year.  If no, please type "N/A"
Have you had a homebirth previously? (If looking for planned hospital birth, please type N/A) *
Why are you interested in homebirth? (If looking for  planned hospital birth, please type N/A) *
What do you envision your birth will look like? *
How does your partner or other family, friends or your planned birth supporters view homebirth? (If looking for  planned hospital birth, please simply describe your support system)
 *
Are you currently taking any medications? If so, please list the name of the medication, dosage, frequency, and reason for taking it.  If no, please type "N/A" *
Any fears, concerns, or other questions you’d like to discuss?
 *
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