Name and contact details of both you & your partner (inc number and email):

Address:

Due date:

Where are you having the baby:

Tell me about your pregnancy, how are you feeling? Who’s your prenatal care provider?

What has been your birth culture and conditioning growing up? What comes to your mind when you think of birth?

Describe the support you would you like to receive from me for each of - pregnancy, birth and post partum?

How do you envision your birth?

Do you have any fears or concerns about this birth?

Who do you see being present at this birth and what will the roles and duties be for each? E.g what do you envision your partner doing, your doula, midwife and/ or OB?

Have you had any traumatic birth experiences or life traumas that you believe could impact your birth? E.g abuse, illness, accidents

If you have had a previous birth — when did you go into labour with this baby? How far along were you?

If you have had a previous birth/s tell me a little bit about it. What was positive and what was negative?

Were you satisfied with your previous birth care providers? Why or why not?

What do you need to feel safe in day to day life? How do you think you can bring this into the birth space?

Tell me a bit about your post partum period? What’s important to you post partum? How do you envision this time? Do you have a support network around?

On a scale of 1 to 10 (with 1 being easy and 10 being really hard) - how do you find it is to ask for help from others?

Do you have any dietary requirements?