Pre-Interview Exploration Form - Mother

All information is confidential and not disclosed or shared without client’s written consent

How did you hear about us?*
Have you given birth before?*
Where do you plan to give birth?*
Type of Care Provider*
Have you taken a childbirth preparation class? *
(in regards to your labor/birth, your caregivers or your chosen birth place)
Do you plan to breastfeed?*
Are there any preferences for either your birth or postpartum you would like to discuss? *
(particularly those inspired by ethnic, cultural, or religious beliefs and/or traditions)
(i.e. nausea &/or stomach upset, verbal, going internal, grinding teeth, etc. + area of body)
(i.e. distraction, movement, turning inward, self medicating, cannabis, companionship or other)
Have you experienced any sexual or gynecological trauma?*
Please finish this sentence
SUBMIT
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