Client Information Client Info Name * First Name Last Name Email * Telephone Number Address Partner Info Name First Name Last Name Telephone Number Birthing Info Estimated Due Date Do you know the sex of your baby? Girl Boy It will be a surprise Do you have a name for your baby? Where are you planning on giving birth? If you have had previous births, miscarriages, or abortion experiences what were they like? What about those births would you like to be the same or different this time? Are there any special circumstances with this pregnancy that may affect your plan for the birth? What is most important to you about your upcoming birth? When you look back on your birth and describe why it was a good experience, what will you say? If applicable, what is most important to your partner about your upcoming birth? When your partner looks back on the birth and describes why it was a good experience, what will they say? Do you have any specific concerns or worries regarding this birth? And your partner? Birth Education Where has most of your knowledge about childbirth come from so far? What books, films, or shows have you watched about birth? Are you taking / will you be taking prenatal classes? yes no undecided If you are taking a prenatal class, where and when will it be? Are there specific topics you would really like to learn more about? Is there anything else you would like me to know as we begin working together? Thank you!