New Client - Postpartum Intake Form Name Mother * First Name Last Name Name Partner First Name Last Name Email * Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Tell me a little bit about yourself and your pregnancy journey so far Estimated due date: * Tell me about your family, who lives in your home? * Tell me a little about who is in your village (family, friends) do they live nearby? * If you are taking maternity leave, when do you plan on taking it? How long will your partner be able to take off once baby has arrived? * How are you feeling in your pregnancy? (Physically, Mentally, Emotionally) * What do you want your ideal Fourth Trimester look and feel like? How can I best support you during our sessions? (For example, making you food, laundry, emotional support, helping you with self care and rest practices (hot shower/ running you a bath/ foot soak)? * When thinking about rest and quiet time, what do you enjoy most? * Long hot shower Soaking in a bath Eating nourishing food and snacks Getting out in nature/fresh air Reading a book Meditation A moment alone Journalling Sleep/rest Catching up with friend Other: Is there anything else you would like me to know about yourself, your family or your needs?Anything else you would like to share with me? * How did you find out about Empowered Birth and Beyond? * Thank you!
