The Milk + Honey Co.

Maternal + Infant Care Intake Form

Congratulations, Honey!!

Thank you for choosing The Milk & Honey Company to be part of your pregnancy and birth journey. This questionnaire helps us understand your health history, preferences, goals, and how we can best support you and your family. All information is kept confidential and is used only to provide individualized, evidence-informed, and compassionate care. I currently offer space for 2 clients per month. I encourage you to book your consultation as soon as possible to chat. Once you have submitted your request you will be contacted within 24-48 hours for a complementary phone consultation during your preferred time.

Full Name

Phone Number

When is the best time to contact you?

What is your address?

What is your zip code?

What is your birthdate?

How many weeks pregnant are you?

When is your estimated due date?

Is this your first pregnancy?

Yes

Medications:

Allergies:

Please list your provider's name, practice's name, and number.

Where will your birth take place?

Home

Birth Center

Hospital

What type of birth do you desire?

Undisturbed Birth

Medicated/Pain Management

Cesarean

VBAC

Which services are you interested in?

Birth Doula Care

Breastfeeding Doula Care

Monthly Bodywork Care

Other

Are you comfortable with our doula trainees shadowing/supporting prenatal, birth support, lactation or postpartum visits?

Yes, I am open to shadowing/supporting my journey

No, I would prefer not to at this time

What are your goals for this pregnancy?

Who is your partner/birth support person, name and phone number?

Have you experienced any trauma that may affect your birth experience?

Are there cultural or spiritual practices you would like incorporated into your care or birth?

Why would you like to work with The Milk & Honey Co.?

We love word of mouth. Shout out who referred you to The Milk & Honey birth services.

You understand I am a highly skilled doula & am not providing medical advice and that my coaching should in no way replace sound treatment from a licensed health care provider. The services you receive are not licensed or regulated by the government.