Intake forms

for new patients

If I have never worked with you before, please take the time to fill out the appropriate intake forms for the following services. You may do this after booking, before your session. Please be as thorough as possible. The more I know, the more I can help!

Prenatal Bodywork Intake

Client Information

Name *

Name

First Name

Last Name

Email Address *

Have you scheduled your appointment yet? *

Yes

If yes, please provide the scheduled date

YYYY

Prenatal Information

How many weeks will you be at our appointment? *

Approximately when are you due? *

Approximately when are you due?

YYYY

How has your pregnancy been so far? *

What pregnancy symptoms are you experiencing? *

Any aches or pains that you have not mentioned above?

How many pregnancies have you had? *

Where will this baby be born? *

Are you hoping for a specific provider to attend your birth?

Are you considered high risk for any reason?

Are you doing any form of exercise?

Are you in a supportive relationship?

Yes

Do you have a support team for after the birth?

If you are working, how long is your maternity leave?

Do you have any fears, rational or not, that are overwhelming?

Doula Information

Doulas have been show to decrease: C-sections by 28% Dissatisfied with birth experience by 34% Use of Pitocin by 31% newborn admittance to nursery by 14% use of pain medications by 9%

Do you have a Doula? *

Yes

If yes, who is your Doula?

Do you have a postpartum Doula? *

Yes

I understand that Chloe does not physically turn breech babies, but can gently create space for them to turn on their own. She also has other resources, just ask! *

Yup, Got it!

Hours of Operation

By appointment only Monday - Saturday

Monday - 10 -3:30
Tuesday - 10-4
Wednesday - 10 - 1
Thursday - 11-5:30
Friday - 10 - 3:30
Saturday 11-4

*If you need a fertility, prenatal, or infant session ASAP and do not see something immediately, please reach out.

Pricing

Payment is not required at time of scheduling

Fertility Awareness Consult - $50/hr
Infant Bodywork - $50/hr
Any 60 minute session - $60
Any 90 minute session - $85
Any 120 minute session - $110
Initial Maya Abdominal Therapy Intake + Session - $95

Check out the scheduling site for the most current series & package deals.

Address

122 North 3rd Street
Marquette, MI, 49855
United States