Intake Form | Simply Holistic Motherhood

The following questionnaire is designed to help me understand your unique needs and preferences as an expectant or new mom.

Your responses will enable me to tailor a written personalized postpartum plan that supports you effectively during this special time. Please answer the questions as honestly and thoroughly as possible.

Date and time

Month

Day

Year

Time

HoursMinutes

First name

Address (city and state only)

Are you currently pregnant or did you already give birth?

How many children do you have?

What is your primary reason for seeking out holistic postpartum resources?

What type of postpartum resources are you looking for? Please list in order of importance. (e.g. support groups, naturopathic doctor recommendations, therapists, worksheets, book recs, holistic products, etc.)

Have you taken any prenatal or postpartum classes?

Yes

Are you currently using any postpartum resources or services (e.g., postpartum doula, lactation consultant, therapist)? If yes, please specify the services.

Are there specific resources you feel you need more information or access to (e.g., integrative wellness, spiritual or religious support, mental health)

Do you have a history of anxiety or mental illness?

Do you have a consistent and reliable support system? (family, friends, partner).

Are there any cultural or personal preferences that should be considered when creating your plan? Explain.

Anything else you would like to share?

Signature

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How would you prefer your individualized plan to be delivered?

Written document emailed to you

Mailed to you

Thank you for taking the time to complete this questionnaire. Your responses are valuable in helping me support you during your postpartum journey!

Disclaimer and Consent