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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?
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?
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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.
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