Baby Moon Birthing Services Intake Form
Greetings!!

Welcome! I'm Cathleen, a Certified Full Spectrum Spiritual Birth worker specializing in Postpartum Healing Care and Student Midwife. Im passionate about Holistic Care and the overall wellness of women throughout their birthing journey and beyond. I am here to support, guide and empower you on the sacred journey of motherhood. 

Honored that you are considering me to support your birth and or postpartum journey!

Please complete the form below. Take your time and give thoughtful answers. I'll get back to you with additional information once I review your form within 24-48hrs. Feel free to reach out to me if you have any additional questions and would like to chat on a call so we can see if our energies align.

Your Sistar in Wellness,

Cathleen
Email *
How did you find me? *
Who can I thank? Name of Person who referred you to me. Please write "NA" if not applicable *
Whats your name? (First and Last Name) *
Whats the best way to connect with you? *
If you answered "call" as your best way to connect with you, please share your number here. If not write "N/A" *
What type of Birth support are you seeking? *
Required
If currently pregnant, is this your first, second or third pregnancy? *
What is your EDD (expected date of delivery)? *
What City & State are you Birthing in AND OR what city and state do you live in? *
What is your vision for your birth? *
Who is your care provider(s)? What is the name of your OB or midwife or endocrinologist? *
If you are pregnant, are there any health concerns that you are facing this pregnancy? ie pre-diabetic, high blood pressure *
What experiences (if any) have you had related to childbirth? What stories or myths about birth have shaped your current views? *
What are you looking for from a birth or postpartum support person? What type of person? *
Are you considering breastfeeding? *
Do you have an idea of the type of birth experience you desire? *
Do you have any fears around birth or experienced any traumas in previous births?  *
If you answered yes in the previous question would you like to share? *Any information shared here is safe guarded and will not be shared. *
How would you describe your current eating habits? *
Are there any special considerations or anything else you'd like me to know as we procure support for you? *
If you have been pregnant/birthed in the past, have you had symptoms or experienced postpartum depression, PTSD, postpartum anxiety, if so please share your experience. *Any information shared here is safe guarded and will not be shared. *
What do you anticipate your needs will be after the birth of your baby? *
For Postpartum Care Services ONLY: Does your family have a certain particular cooking style? Special Dietary needs/restrictions? ie non dairy, vegetarian, vegan. Write NA if not applicable  *
What is your budget? Please Note a 25% is given off Postpartum Services if selecting birth & postpartum support with me.  *
Are you interested or in need of financial assistance or interested in support at a reduced cost? (pls note ONLY Westchester County families can be considered at this time)  *
Required
Are you interested in any other services as an add-on option? *
Required
Anything else you'd like to share? If not, please write "N/A" in the space below. *
I understand that the answers I have provided and the information disclosed is confidential and secure. My information will never be shared with third parties. I realize that my information will only be utilized internally to find the best possible match for support. *
Required
A copy of your responses will be emailed to the address you provided.
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