Home Birth Inquiry-Questionnaire
Thank you for taking time to complete this inquiry form. The information you provide on this form will assist us in understanding your desires and expectations for midwifery and home birth care and to determine your candidacy. PLEASE NOTE: Please see availability calendar before completing this form. We are NOT accepting first time moms at this time. Inquiries submitted for unavailable dates will not receive a response. The number in parenthesis reflects the current available reservations for that month.  Returning clients may text us directly!

 2024​

September (1)

November (3)

December BLOCKED (0)

2025

January BLOCKED (0)

February (3)

March (3)

April (2)

May (3)

June BLOCKED

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Email *
Full Name *
Phone Number *
Which service are you interested in? *
What is your age? *
What city to do you reside? *
What is your estimated due date? Please review the availability calendar above. *
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What number pregnancy is this for you? (1st, 2nd etc..) *
How many living children do you have? *
Have you given birth via cesarean section? If so, How many? *
Do you have any medical problems? Any other surgeries in the past? Taking medication? *
Have you given birth at home before? *
Required
Have you had an unmedicated birth before? *
Required
Why are you interested in home birth and what are 3 main goals you would like to achieve during your pregnancy and birth experience? *
What research have you done regarding home birth? (books, online sources, documentaries etc).  *
How did you hear about Birth by Grace Midwifery? *
Feeling supported by your family/friends/partner is very important when planning for home birth. Does your partner/family support your desire to give birth at home? *
Do you live a healthy lifestyle? (healthy eating habits, exercise etc.) *
Opting for home birth means you are opting for a completely unmedicated birth. How do you plan to prepare for this experience? How do you cope with pain? *
Do you have any basic knowledge about child birth? (i.e. length of labor from start to finish, stages of labor, etc) *
 Hiring a doula is a requirement for first time mothers. Are you prepared to hire a doula to support you through pregnancy and labor? *
Midwifery and home birth care is a partnership. This type of concierge-style maternity care encourages mothers to be active participants in their own care. There is also a higher level of responsibility that is required when planning for a non-medical approach to your maternal health care.  Are you willing to accept this level of accountability , suggestions & modifications necessary throughout your care to achieve the goal of home birth? *
Do you understand that Birth by Grace can not guarantee that you will have a home birth due to potential unforeseen circumstances that can arise at any time? *
If customizing care, please specify which services you are interested in. For example, labor management, prenatal care only, postpartum care, testing or blood work, doula referral, etc). 
A copy of your responses will be emailed to the address you provided.
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