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The Birthgiver's Path - Intake Form

Welcome! I'm so honoured you've chosen The Birthgiver's Path. This form helps us begin with intention, clarifying your current goals and support needs. Please take a few minutes to complete this before booking your first session.

Full Name

Name Your Preferred to be called ( if different than above)

Date of Birth

Current Occupation

Email Address

Phone Number (optional)

Mailing Address

Current Life Status ( married, single, divorced, separated, common law, children (ages) other

Do you currently use Voxer for communication?

Do you currently use Voxer for communication?
A
B

If yes, what is your Voxer handle?

Are You Currently Pregnant?

Are You Currently Pregnant?
A
B
C

If Yes, what is your Estimated Due Date?

If no, are your trying to conceive, planning a pregnancy or in your postpartum journey?

Is this your first pregnancy

Is this your first pregnancy
A
B

If NO, how many pregnancies and births have you had?

What are your top three priorities for support? (ex. emotional support, advocacy, partner involvement, postpartum planning)

Who is your primary care provider?

Who is your primary care provider?

Where are you planning on birthing or have you most recently birthed?

Where are you planning on birthing or have you most recently birthed?

How would you describe your current emotional state on your journey?

How would you describe your current emotional state on your journey?

Do you have access to any of the following check all that apply?

Do you have access to any of the following check all that apply?

At this time, what kind of support are you looking for?

At this time, what kind of support are you looking for?

Do you agree to the following:

This package valid for 12 months from the date of purchase.

This package valid for 12 months from the date of purchase.

This package is non-refundable.

This package is non-refundable.

I acknowledge that coaching is a collaborative, self responsible process and not a substitute for medical or psychological care

I acknowledge that coaching is a collaborative, self responsible process and not a substitute for medical or psychological care

I consent to email communication for scheduling and coaching support.

I consent to email communication for scheduling and coaching support.

I understand there is a required 24 hours notice to reschedule my sessions

I understand there is a required 24 hours notice to reschedule my sessions
A
B