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2025 Booking
Birth
Fresh 48
Newborn
Families
Mini Sessions
First Year
Storyteller
Studio
Client Closet
Journal
Cart
0
Information
2025 Booking
Birth
Fresh 48
Newborn
Families
Mini Sessions
First Year
Storyteller
Studio
Client Closet
Journal
by Beth Farnsworth
New Client Intake Form
Name
*
First Name
Last Name
Partner's Name
First Name
Last Name
Email
*
Your Cellphone Number
*
(###)
###
####
Doctor/Midwifes/Practice Name
*
First Name
Last Name
Hospital/Birth Center for Delivery
Your Home Address
About Your Baby
Estimated Due Date
*
MM
DD
YYYY
Baby's Gender
Girl
Boy
Unknown
Baby's Name
if known
Planned Method of Feeding
Breastfeeding
Formula Feeding
Both
Not sure but would like more information
Your Health
Please state your general health
Do you have any allergies I should be aware of?
Explain any complications you have had with this pregnancy, any restrictions your caregiver has given you, and any medications you are currently taking.
*
Have you had any struggles with any of the following mental health diagnosis?
Depression
Anxiety
OCD
Other
Are you a survivor of sexual assault or abuse?
Yes
No
Preparation for Birth
Have you given birth before?
*
No
Yes, Vaginally Only
Yes, Cesarean Only
Yes, Vaginally and Cesarean
How many pregnancies have you had?
How many living children do you have and what are their ages?
Have you taken or are you planning on taking any childbirth education classes? If so, what are they and where are you attending them?
Please list any other classes you have taken or plan on attending.
Ex: Breastfeeding, Infant Care, Infant CPR, Sibling classes, etc...
Who do you plan to have assist you with your labor?
*
Partner
Doula
Mother / Mother-In-Law
Sister
Friend
Other
How do you feel emotionally about giving birth?
Very confident
Somewhat confident
Nervous
Very afraid
What is your biggest fear going into this birth?
Do you have a birth vision planned?
Yes, It is a final copy
Yes, but it is a draft and would like some help
No, I would like some help writing one
No, I have no interest in one
How do you feel about interventions in labor/delivery?
What type of pain management are you looking to have?
Comfort Measures
IV Medication
Epidural
Other
None
What type of comfort measures would you like to use in labor?
Distractions
Breathing Patterns
Massage
Birth Ball
Walking, Dancing, Swaying
Water (Tub/Shower)
Visualization/Imagery
Focal Points
Aromatherapy
Music
What is your vision for this birth?
*
What are your expectations of me as your doula?
*
Do you have any specific ideas about what kind of support you might need in labor?
Ex: Aromatherapy, Massage, Hip Squeezes, Counter pressure, Vocal support, etc
Are there any special positions, breathing or relaxation techniques that you have practiced or would like to use during labor?
Ex: Guided mediations, Hypnobirthing, etc
Any other questions or concerns?
Thank you!
