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PREGNANCY INTAKE

Today's Date

YYYY

Name

First Name

Last Name

Premarital surname, if applicable

Do you have pronouns?

How do you prefer people refer to you? (i.e dey/dem, she/her, he/him, ze/zir)

Phone

Country

(###)

###

####

Date of Birth

Residence Address

Country and postal code included

Are either you or your partner(s) employed by law enforcement? (police, ICE, et al.)

Yes

Other

This next series of questions will ask you about your current pregnancy, as well as personal and medical history. Take your time and share what's comfortable.

What brings you to this service?

How far along are you at the time of filling this out?

Do you know your expected due date?

Have you been pregnant previously?

If applicable, please include # of times.

Have you given birth previously?

If applicable, please include # of times.

What does your team of support look like? Who's helping along the way, as it pertains to your pregnancy and baby?

This can look like: Biological and chosen family, friends, spouses, godparents, therapists, herbalists, midwives, doulas, pastors and other clerical figures, you're welcome to think expansively. 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 and birth?

If applicable, what does this look like?

Have you experienced any struggles with fertility or sustaining a pregnancy previously?

Please list physical, relevant spiritual, or dietary allergies/restrictions.

Indicate your medical history. Do you have any health conditions, medications you're actively taking, a history of past surgeries?

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

What's sensitive for you? (emotionally, physically, spiritually) Please indicate any triggering topics or situations that you'd require extra care around if it were to come up.

Select preferred way of experiencing these services.

Remote

In-person

Combination of remote and in-person service

Optional: If you're a former pre-pregnancy client, what about your experiences have changed between then and now?

Select "Yes" if you certify that you thoroughly understand the birthwork services of (Un)Veiled Divine Technologies and consent to receiving birthwork services through (Un)Veiled Divine Technologies.

If you have any questions leading up until this point, first go back to Tay and seek clarity.

Yes