New Client Intake Form
I would love to learn a little bit about you before our visit together. Please fill out this form to the best of your ability.

Thank you!

Leah Pinault
Email address *
Name *
Your answer
Phone Number *
Your answer
Email *
Your answer
Home Address *
Your answer
Your Age *
Your answer
Your Occupation *
Your answer
Partner's Name, if applicable
Your answer
Partner's Phone Number
Your answer
Partner's Email
Your answer
Partner's Occupation
Your answer
Care Provider *
Your answer
Birth Location (with address) *
Your answer
Estimated Due Date *
MM
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DD
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YYYY
Sex of Baby(s)
Planned Method of Feeding *
Would you like to share information on previous pregnancies? *
Your answer
Have you given birth before? How was your experience? *
Your answer
Any personal health concerns / allergies I should be aware of? *
Your answer
How has your pregnancy been thus far? Please let me know of any complications, restrictions, medications, etc. specific to this pregnancy. *
Your answer
Have you taken any childbirth ed classes yet? If so, what? *
Your answer
What does your ideal birth experience look like? *
Your answer
What do you anticipate will be your greatest source of strength/comfort while in labor? What comforts you when you are not feeling well or are anxious? *
Your answer
What do you anticipate will be your greatest challenge while in labor? Do you have any concerns / anxieties? *
Your answer
Do you need any referrals for your physical comfort during your pregnancy (acupuncturist, nutritionist, chiropractor, physical therapist etc)? *
Your answer
Is there anything else you think I should know?
Your answer
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