Date
Name
*
First Name
Last Name
Complete Address
Phone
Day & Evening
(###)
###
####
Mobile Number
*
(###)
###
####
Email
*
Partner's Name
*
First Name
Last Name
Partner's Email & Mobile #
*
Birthdate
MM
DD
YYYY
Age / Height & Weight / Blood Type
Ancestry/Ethnicity
Family & Living Situation
Occupation
Allergies
Midwife/Doctor/Care provider
Include phone numbers
Other health care providers/insurance providers
Medical conditions/ procedures during the last 7 years
What is your regular exercise routine and recreational exercise? How often?
What do you do to relax and destress?
List any supplements or medications you are taking and for what purpose for each
How many children do you have? Please provide their names and ages
How do you feel about being a mother?
Share your thoughts and emotions about your motherhood journey so far.
Birth and Health History
Please share your birth experience(s) and any complications you faced, if applicable.
How is your health presently? Are there any health issues, diseases, or recent surgeries we should be aware of?
Please describe the condition and tendency of your:
Skin
Hair
Nails
Please list any addictive behaviours (past and present use and abuse of alcohol, drugs, tobacco, birth control pills, caffeine, food, codependency, workaholism…):
Do you have any injuries? If so, where are they located and how do they affect you?
What are toxins now and past- food and environmental exposure, parasites?
Daily Life
Describe a typical day in your current schedule as a mother. What are your daily routines and activities?
Current Stresses
What are the present stressors or challenges you are experiencing in your life, especially related to motherhood?
Are you presently exercising or involved in activities?
Financial Situation
How do you feel about your financial situation presently? Are there any concerns or challenges related to your financial well-being?
Relationship Status
Are you married or in a committed partnership? If yes, please provide your partner's name and career, if comfortable sharing.
Life Aspirations
What do you want your life to look like, feel like in this next year?
Personal Growth and Healing
Are you aware of any areas in your life where you may need healing or personal growth?
Desired Support
What specific areas do you need support with the most during the program? (e.g., birth preparation, postpartum care, self-care, confidence, relationships, baby care etc.)
Dreams and Goals
Is there anything you wish to be or do now, which may differ from your current situation? Share your dreams, ambitions, and aspirations.
Unlimited Support
If money were not an issue, what kind of support or assistance would you wish for during your motherhood journey?
Additional Information
Is there anything else you would like us to know or any additional information you'd like to share?
Consent
*
By submitting this intake form, you acknowledge that the information provided is accurate and that you consent to participate in our programs.
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