PRE-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 as well.

Maiden name (if not applicable, leave blank)

Pronouns

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

When were you born? (Date)

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?

Have you been physically pregnant previously?

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

Is there a specific time you're seeking to be pregnant by?

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

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 this pre-pregnancy period?

What does this look like?

Any struggles or complications with conceiving or sustaining pregnancies before? Or struggles with fertility?

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 an idea about your everyday diet.

Tell me about your medical history. Are you on any medications? Health conditions? Past surgeries?

Are there any triggers that you'd want me 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.

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.

How are you feeling after filling this out?

+ and last comments/things to know?