knowing me,

knowing you.

When you get a minute, please fill out this get to know you survey - it helps me to

a) get to know you and b) plan how to tailor my services and approach to your unique scenario.

I also would hate to give you nuts if you’re allergic; it’s the small things, you know?

Your Name

First Name

Last Name

Your Date of Birth

YYYY

Planned Birth Location

Care Providers or Programs (Obstetrician, Private Midwife, MGP or Continuity of Care Programs etc)

If birthing publicly in hospital, please write Public.

Estimated Due Date

YYYY

Phone

(###)

###

####

Your Partner's Email

this is for the contract to be signed electronically, if you are flying solo please just re-enter your own email address x

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Partner/Support Person's Name

First Name

Last Name

Phone

(###)

###

####

Your Payment tier (Birth Support Package only)

Link to decide which tier represents your financial situation: https://www.radicalhistoryclub.com/sliding-scale

Tier 1 / $2000

Tier 2 / $2800

Tier 3 / $3700

How would you like to make payment?

How has your experience been so far? Anything that is important to know in order to support you well?

Please list the ways in which you'd like to be supported and what is really important to you.

Any worries, concerns or known knowledge gaps you want to fill?

In a sentence tell me about your relationship with your support person.

RELEVANT ONLY FOR BIRTH SUPPORT. A nice question to do together.

Do you (or your support person) have any allergies, dietary preferences or medical concerns you think are important to be aware of?

Describe how you want to feel in your labour and birth and what that looks like to you.

RELEVANT ONLY FOR BIRTH SUPPORT

Describe how you want your postpartum to feel and look like.

How would you introduce yourself in a couple of sentences?

contact me

0434 037 259 or josie@lovespacedoula.com