Pregnancy arsenal intake

One step closer to being able to powerfully work together.

Before you begin:

Please fill this form out to your best capability. It is for UDT records only.

Name

Include any preferred names, and your maiden if applicable as well.

Pronouns

i.e dey/dem, she/her, they/them, he/him, etc.

When were you born? (Date)

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

Country

(###)

###

####

Are you a member of law enforcement (police, ICE, etc.), or partnered with a member of law enforcement?

Why are you interested in this service?

How far along are you at the time of completing this form?

Do you know your expected due date?

Have you been physically pregnant previously?

Have you given birth previously? If so, how many times?

What does your team of support look like, when it comes to those helping you along the way, in the context of your pregnancy + the baby?

Blood and/or chosen family, friends, spouses, godparents, herbalists + Root Doctors, midwives, doulas, etc. If you do not yet know, what would you want this team of support to look like?

Do you plan to receive any form of support from a partner throughout your pregnancy?

What does this look like?

Do you plan to receive any form of support from a partner after the baby is born?

What does this look like?

Do you have any triggers you'd like us to know about?

Anything/Topics/Situations that you are emotionally, spiritually, and/or physically sensitive to, or could potentially be re-traumatizing to interact with or hear about.

Tell us about your medical history. Are you on any medications? Health conditions?

Any physical, noteworthy spiritual and/or dietary restrictions or allergies?

What's your food history? What did you grow up eating and what foods do you often eat nowadays? Give us an idea about your everyday diet.

Do you understand that this is an ongoing service, until when you are ready?

Have you reviewed the listed rates on the Birthwork page of the website?

If any questions, please contact me and let me know.

Are you seeking a solely remote service, or a combination between remote + in-between work?

Due to COVID-19, in-person measures are still an option, however, an increasing of physical and spiritual security/safety measures would need to be taken on both parties' ends to ensure good protected health. Future conversations will any parties involved would need to be had to strategize accordingly.

If you filled out the pre-pregnancy intake form prior to this, has anything changed for you and your experiences between now and then?

You're welcome to interpret this however you would like!

How are you feeling after filling this out?

And, and last comments or things to know?