Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
Home Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Age
Name
First Name
Last Name
Phone
(###)
###
####
Email
How many children do you have
0
1
2
3
4
5
6
7
8
9
10
Estimated Due Date
*
MM
DD
YYYY
Current Weeks Gestation
*
Desired Birth Location
*
Care Providers Name
*
Care Providers Practice Name
*
Care Providers Phone Number
*
(###)
###
####
Previous Births
*
0
1
2
3
4
5
6
7
8
9
10
Previous Miscarriage
*
No
Yes
If yes, please provide details below:
How do you want to feel?
How do you want to feel while giving birth? (i.e., empowered, safe, private, autonomous, confident, loved, respected, flexible, strong, etc.) Feel free to use your own wording here.
Tension - Physiological
How do you manifest tension? i.e., difficulty breathing, sweating, crying, panic, nausea, moaning, grinding teeth, clenching fists, racing heart, etc. List all that apply and feel free to add your own.
Coping when unwell
What makes you feel better when you are sick, stressed, anxious, tense, or in pain? How do you comfort yourself? i.e., distractions, rest, warm soup, talking it out, movement, silence, turning inward, laughter, self-medicating, OTC drugs, hot/cold therapies, sleeping, companionship, food, meditation, essential oils, etc. Include all that apply and feel free to add your own.
Strongly wish to avoid during labor and birth
Select all that apply
Preferred Coping Techniques
Please check any coping techniques you plan on using.
Most Important Elements of Your Birth
Select top 7