Parent Profile — Managing Overwhelming Moments

Parent Profile

I appreciate your interest in my birth class! If a date is listed on my site there is still space available. To register, please complete the following form. You will receive an email confirmation within two days of submission with payment instructions.

Date of Class

Name

Age

Occupation

Cell Phone *

Cell Phone

(###)

###

####

Partner's Name

Age

Occupation

Cell Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Estimated Due Date

Anticipated Birth Location

Midwife or Doctor's Name

Birth Doula

Birth Doula Name

Have you had any previous pregnancies / births (including miscarriage, abortion, etc.)? Please describe

Have you experienced any problems or complications with your pregnancy so far?

Does either partner have any health conditions that I should be aware of?

Do you feel comfortable with your chosen birth environment and caregivers?

What are your primary wishes for your birth (aside from healthy mom and baby)? Are you hoping to have a natural birth? What does a “natural birth” mean to you?

Do you have any previous experience with mind-body or holistic approaches to health and wellness? Explain.

Have either of you ever witnessed a birth?

What books have you been reading (or films have you seen) about childbirth and parenting? Which have you liked the most?

Have you taken any other childbirth education or labor preparation classes or workshops?

Do you have any previous experience with newborn care or breastfeeding? Any particular concerns about either of these?

Do you have any special concerns about your pregnancy or birth? Is there anything else that you would like me to know about you and your family?

Do you have a history of depression or anxiety? If so, what methods have you used in the past to work with / through these feelings.

For Childbirth Education Clients

Why did you choose to take this class? What are the main things you hope to learn?

For Postpartum Clients

Why did you choose to hire a postpartum doula? What are the main things you hope to gain from having my support?

Who else will be present in the first few weeks post-birth (family, friends)? How do you foresee these relationships affecting you?

Describe your sleep patterns pre-pregnancy. What time did you go to bed? What time did you wake up? Did you sleep uninterrupted? What do you expect sleeping with a newborn to look like?

Describe your pre-pregnancy nourishment habits. Did you eat three meals a day or graze? Eat in bed or at the table? What are some of your favorite foods? Do you have any allergies or dislikes?

Do you have any pets? Do they need special care?

Is there anything noteworthy about how you keep your home that I should know ahead of time?

Do you have any additional concerns about your postpartum experience? Is there anything else that you would like me to know about you and your family?