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Birth Reflection Session Intake

Full Name

*

Email Address

*

Phone Number

*

Baby's Birth Date

*

Was this your first birth?

*

Was this your first birth?

A

Yes

B

No

Briefly describe your birth experience in your own words.

*

What parts of your experience feel unresolved, confusing, painful, or emotionally heavy?

*

Are there specific moments during labor, birth, or postpartum that continue to replay in your mind?

*

Did you feel informed and supported during your birth?

A

Mostly yes

B

Somewhat

C

No

Have you previously processed this experience with anyone?

*

Have you previously processed this experience with anyone?

Partner

Friend

Therapist

Doula

No

What would feel most supportive during our session?

*

What would feel most supportive during our session?

Emotional processing

Understanding medical events

Validation

Preparing for future birth

Faith-centered encouragement

Is there anything that you are nervous about discussing?

*

What are you hoping to leave the session with?

*

Emergency Contact Name & Number

*

Disclaimer Agreement

*

Disclaimer Agreement

Legal Checkbox: This session is educational and emotional support only and does not replace therapy, medical care, or mental health treatment.