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Client's Name
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Other Phone Number
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Address
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Client's Age
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How many pregnancies (including this one) have you had?
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How many children do you have (including this baby)?
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Client's Partner or Birth Companion's Name (if applicable)
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Age
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Relationship to Client
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When are you expecting your baby?
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EDD or Month is fine
Who is your care provider (doctor, midwife, group)
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Where are you planning to give birth?
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What are you most interested in learning about pregnancy, birth, and parenting?
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Is there anything else I should know about you, your family, or your birth history?
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Which class are you registering for?
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April 11, 18 & 25 at Little Wares
Private Class (schedule TBD)
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Home
About Me
Doula Services
Classes
Other Services
Register/Hire Me
Hire me as your doula
Register for a Class
OTHER SERVICES CLIENT INFORMATION FORM
Contact Me