New Client Intake Form
We would love to learn a little bit about you before our first visit together. Please fill out this form to the best of your ability and let us know if there is anything else we may be missing. Thank you!
Email address *
Your Name *
Your Phone number *
Your Birthdate
MM
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DD
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YYYY
Your occupation
Partner's Name, if applicable
Partner's email
Partner's Occupation
Care provider *
Where will you be giving birth? Hospital, birthing center, home? Not sure yet? *
Estimated Due Date *
MM
/
DD
/
YYYY
Planned Method of Feeding
Please let us know about your general health or if you have any chronic conditions we should be aware of:
Have you given birth before?
Would you like to share information on previous pregnancies?
How has your pregnancy been thus far? Please let us know if you've had any complications, restrictions, or are on any medications specific to this pregnancy.
Have you taken any Childbirth Preparation/ Education classes?
Are you interested in taking Childbirth preparation classes with Expecting(nyc)?
What does your ideal birth experience look like?
Who do you plan to have with you at the birthing location?
Do you have birth preferences planned?
What comforts you when you are not feeling well? What calms you when you are feeling anxious?
What do you anticipate will be your greatest source of strength/comfort while in labor?
What do you anticipate will be your greatest challenge while in labor?
Do you have any concerns regarding the birth?
Do you need any referrals for your physical comfort during the pregnancy (acupuncturist, nutritionist, chiropractor, physical therapist etc)?
Is there anything else you think we should know?
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