Intake Form for Baby Clinic

Intake Form for Baby Clinic

Child's Name and Gender:

Parent(s) Name(s):

Child's Birth Date:

Place of Child's Birth:

Following is a list of pre-natal and birth scenarios that may possibly have affected your child. Some questions may be difficult to answer due to lack of recall or original information, do not worry, we will do our best to undertake further research and exploration, with a goal to improving your intuition and your memory. If you find there is not enough space provided to answer the questions, feel free to use the reverse side of the page. Please be as accurate and honest as possible when answering these questions. Knowing the truth, when held empathically and consciously only furthers our ability to help resolve pre- and perinatal shock and trauma. If you are not sure you know the answer, report as your intuition suggests, even if your intuition says "I don't know". Please be assured this information will be kept confidential.

Conception

Was the conception:
a conscious, positive intention? Yes No Don't Know

a surprise? (unintentional) Yes No Don't Know

an unwanted conception? Yes No Don't Know

a forced conception? Yes No Don't Know
(rape, unwilling partner, incest)

a multiple conception? Yes No Don't Know

Was birth control being used? Yes No Don't Know

Were alcohol or drugs in the system, Yes No Don't Know
or recently in the system of either parent?

Was there exposure to teratogenic substances? Yes No Don't Know
(damaging chemicals)

What was your initial reaction to finding out about the pregnancy, any strong reactions you can remember?

What was the emotional state of the mother during the pregnancy?

What was the emotional state of the father during the pregnancy?

What was the physical state of the mother?

radiantly healthy most of the time? Yes No Don't Know

radiantly healthy part of the time? Yes No Don't Know

illness? Yes No Don't Know

bleeding? Yes No Don't Know

alcohol use? Yes No Don't Know

recreational drug use? Yes No Don't Know

prescription drug use? Yes No Don't Know

smoking or second hand cigarette smoke? Yes No Don't Know

exposure to teratogenic substances? Yes No Don't Know

Rh incompatibility? Yes No Don't Know

dietary issues? Yes No Don't Know

prenatal tests? (amniocentesis, ultrasound) Yes No Don't Know

Were there any stressful events during the pregnancy? (moving, long separation from partner, divorce, death of a loved one, loss of job, etc.)

What was the interpersonal relationship like between the parents during the pregnancy?

Was there any physical or emotional abuse between parents and/or siblings?

Did you or your partner ever fantasize about an abortion?

Did you or your partner ever consider an abortion? If so for how long?

Was there an abortion attempt?

Was there a gender preference expressed by either parent or siblings? What were you/they hoping for? Was this preference expressed after birth as well?

Birth

Where was your baby born?

What was the environmental setting and the mood like during the birth?

What was the relationship like between the mother and doctor or midwife?

What was the emotional state of the mother throughout labor and the birth?

Was the father present? What was his emotional state?

Were siblings present? If so, what were their emotions like?

How long was the labor?

Was the labor induced? If so, by what means?

Was en epidural administered? If so, at what point?

Was the amniotic sac ruptured by the doctor or nurse?

Was the mother given anesthesia and/or analgesia?

Was your baby born vaginally, emergency cesarean or planned cesarean?

Was your baby premature? If so, how many weeks?

At the time of delivery was:
the baby breech? Yes No Don't Know

the cord around the neck? Yes No Don't Know

the cord compressed? Yes No Don't Know

the shoulders stuck? Yes No Don't Know

suction used? Yes No Don't Know

forceps used? Yes No Don't Know

the Ritgen Maneuver used? Yes No Don't Know

there manipulation of head/neck/shoulders? Yes No Don't Know

After Birth

Who was your baby given to immediately after birth?

What was the mood in the room like after the birth? (quiet, joyful, frightened?)

How soon after delivery was the baby's umbilical cord cut, and who cut it?

If you baby was born in the hospital, which of the following occurred?

spanked to induce breathing? Yes No Don't Know

suction from nose or mouth? Yes No Don't Know

vitamin K shots? Yes No Don't Know

heel stick for blood test? Yes No Don't Know

blood transfusion(s)? Yes No Don't Know

removed from mother? Yes No Don't Know

bilirubin lights for jaundice? Yes No Don't Know

incubation? How long? Yes No Don't Know

put into neonatal intensive care? How long? Yes No Don't Know

silver nitrate put into eyes? Yes No Don't Know

circumcision? Yes No Don't Know

surgery? On what? Yes No Don't Know

What was the bonding experience like immediately after birth?

Did you breast feed your baby? If so, for how long?

Were there feeding problems?

Were there sleeping problems? Did your baby sleep excessively?

Was there excessive crying, colic?

What was the overall physical and emotional state of your baby in the days after the birth?

If there is anything else you would like to share, feel free to use the back of this page. Thank you. Please be assured this information will only be used in the context of helping to resolve pre- and perinatal shock and trauma and will be kept confidential.

For Adopted Babies

How did you arrive at the choice to adopt?

What alternatives did you consider before reaching your decision to adopt?

What were you told by the birth parent(s) about why they placed their child for adoption?

Is there history of adoption in the birth family or in your family?

How was your choice to adopt received by your family and friends?

How did you adopt? Privately, designated, or through an agency?

Did you meet the birth parent(s)? Under what circumstances?

Do the birth parent(s) have other children?

Were you present at the birth of your child?

How much time did your child spend with the birth parent(s) after the birth?

What is your situation in terms of maintaining a connection with the birth parent(s)?

If you were not present at the birth, how soon after did you meet your child? What were the circumstances? (travel abroad, foster parents, etc.)

How do you believe, in a spiritual context, this child came to you?

In Vitro Fertilization

If you are comfortable sharing, what were the circumstances that lead you to the choice of in vitro?

How many attempts at fertilization were there?

Was there sperm and/or egg donation?

How many embryos were implanted?

How many embryos survived implantation? How many went full term?

Did you have a reduction, or did you consider one?

Were you put to bed rest? If so, was if due to complications?

Were there specific complications due to multiple births? (preclampsia, toxemia, etc.) Were drugs administered for this?

Was your child or children born prematurely? If so, how many weeks early?

Was our child or children hospitalized after the delivery? If so, for how long?

How much time were you able to spend with them while they were in the hospital?

If there were twins or triplets, were they hospitalized together, or were they separated? What kinds of medical intervention did they experience?