Woman’s intake MamaBebe is committed to your privacy. We will never sell or give away your information. Many sections of this form are optional, and you may skip them. Please fill out the information that you feel is most relevant. At any time you may save and return to fill out this form at a later time. To find the Save and Continue link: Scroll to the bottom of the form. Name* First Last Your date of birth* Month Day Year Phone*Email* Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you currently pregnant or did you have a baby in the last year?* I am currently pregnant I gave birth to a baby in the past year No, I have concerns related to a prior pregnancy or birth No, I want to prepare for conception I'm not childbearing these days MamaBebe prenatal services that I am seeking are:*Check any that apply Prenatal bodywork Body Ready Method alignment & strength activities Craniosacral therapy Myofascial bodywork Somatic bodywork Mindfulness & movement awareness practices Breech balancing Spinning Babies Parent Class I would like support for:*Check any that apply Relief from discomfort Alignment & movement to prepare for birth Open space for my baby to rotate into better position Know what movements my partner & I can do for an easier birth Improve alignment, strength & balance Connect within myself in preparation for birth Connect with my baby in utero Emotional balance through somatic practices Somatic awareness & mindfulness of body Other I would like support for:*Check any that apply Relief from discomfort Recover from difficult birth Rebuild strength & alignment postpartum Body Ready Method for postpartum recovery Emotional balance through somatic practices Somatic awareness & mindfulness of body Other I would like support for:*Check any that apply Relief from discomfort Improve alignment, strength & balance Emotional balance through somatic practices Somatic awareness & mindfulness of body Other My main reasons for taking the Spinning Babies Parent class: Estimated guess date of baby's birth Month Day Year Date of baby's birth Month Day Year Do you have a partner or primary support person for your pregnancy, birth and/or parenting?Please note only the individual(s) who provide you with close emotional support and who will be present at your birth and/or will co-parent with you. Husband Wife Partner Close friend Family member Single parenting by choice Single parenting without partner Name - Husband First Last Name - Wife First Last Name - Partner First Last Name - Close friend or family member First Last Phone - HusbandPhone - WifePhone - PartnerPhone - Close friend or family memberEmail - Husband Email - Wife Email - Partner Email - Close friend or family member Do you identify your gender as being a woman?YesNoGender fluidOtherDescribe your gender identify: What are your preferred pronouns? Does your partner have preferred pronouns? He/him She/her They/them Per/pers Other Other pronouns that your partner prefers: Health conditionsHealth conditions you are experiencing now I am in good health, and not experiencing any of the following conditions. Frequent headaches Persistent pain Tension or soreness in specific areas Sensitivity to touch or pressure in specific areas Sensitivity to vibration Numbness or stabbing pain Incontinence; leaking urine or bowel Pubic bone separation Hypermobility of joints Loss of balance Falls or accidents in the past six months Broken bones in the past six months Sprained joints in the past six months Surgery in the past six months Arthritis High blood pressure Cardiac or circulatory conditions Heart condition that requires that physical activities be medically supervised. Diabetes Chronic fatigue Gut / digestive problems Yeast Infection Auto immune disorder Seizures Respiratory disorders Anorexia or bulemia Other Health conditions you experienced in the pastNote conditions prior to the past six months I have been in good health, and haven't experienced the following conditions. Frequent headaches Persistent pain Tension or soreness in specific areas Sensitivity to touch or pressure in specific areas Sensitivity to vibration Numbness or stabbing pain Incontinence - leaking urine or bowels Pubic bone separation Hypermobility of joints Loss of balance due to dizziness or loss of consciousness Falls or accidents Broken bones Sprained joints Surgery Arthritis High blood pressure Cardiac or circulatory conditions Diabetes Chronic fatigue Gut / digestive problems Yeast Infection Auto immune disorder Seizures Respiratory disorders Anorexia or bulemia Other Where do you experience persistent pain, tension or sensitivity? Head Neck Shoulders Arms Ribs or chest Upper back Middle back Lower back Belly Hips Groin - in front hips & upper legs Pelvic floor and/or perineum Pain during sex Pubic bone Sciatic pain (in buttocks and/or down your leg) Legs Feet Other pain Any further detail on current health conditions that you want to provide: Your support systemDo you have other children?Check all that apply Yes, I have older children who were born to me Yes, we have a blended family Yes, I have adopted children No Other childrenPlease note names & ages Your response to pregnancy: Welcoming Mixed feelings Unwelcoming Additional notes on your response, optional Father/partner response to pregnancy: Welcoming Mixed feelings Unwelcoming Single parenting, no partner Notes on father/partner's response to pregnancy, optionalExtended family response to pregnancy: Welcoming Mixed responses Unwelcoming No extended family Other Additional notes on extended family's response, optional Close friends' response to pregnancy: Welcoming Mixed responses Unwelcoming No close friends who influence me Other Conception & preconceptionYour age at time of conceptionPlease check any areas relevant to conception: Conception was uncomplicated Difficulties conceiving Fertilization assistance History of trauma / abuse Note health conditions that affected conceptionYour prenatal experienceYou are welcome to answer only the questions that are relevant to your concerns for care. Questions include health conditions for your baby and for yourself.Baby Singleton Multiple How many babies in multiple pregnancy?Describe the position of each baby, if over 28 weeksPosition my baby is in - 28 weeks onBabies can move around in any position up until 28 weeks. From 28 weeks on, it's recommended to help baby to be head down. Check any that apply if baby is 28 weeks or older. My baby is 28 weeks or older. My baby is head down My baby is lying sidewise (transverse breech) My baby's head is at the top (breech) Position my baby is in - direction of facingBabies can move around in any position up until 28 weeks. From 28 weeks on, it's recommended to help baby to be head down and in one of the OA positions (described below). Baby's head is on my left side, facing back (LOA) Baby's head is in the middle, facing back. (OA) Baby's head is on my right side, facing back. (ROA) Baby's head is in the front, moving side to side. Baby's head is in the front, but the exact position is unknown. Baby's head is on my left side, facing forward. (LOP) Baby's head is in the back & central, facing forward (OP) Baby's head is on my right side, facing forward. (ROP) Baby's head is in the back, but the exact position is unknown. Baby's head is down, but moves around so much that we don't know where s/he is landing. Baby's head is down, but the exact position is unknown. Baby’s health during pregnancyCheck all that apply for your baby. Separate questions about your health will follow. Baby - healthy and well throughout the pregnancy Baby - health issues or risks during pregnancy Infrequent movement Placental insufficiency In utero growth retardation Placenta previa Risk of prematurity Down syndrome or other genetic differences Other Baby 2 - Health during pregnancyCheck all that apply Baby - healthy and well throughout the pregnancy Baby - health issues or risks during pregnancy Infrequent movement Placental insufficiency In utero growth retardation Placenta previa Risk of prematurity Down syndrome or other genetic differences Other Baby 3 - Health during pregnancyCheck all that apply Baby - healthy and well throughout the pregnancy Baby - health issues or risks during pregnancy Infrequent movement Placental insufficiency In utero growth retardation Placenta previa Risk of prematurity Down syndrome or other genetic differences Other At what gestational week did risks to baby's health become known? Describe health concerns further, if you wishMy baby's health condition changed our care plan. I changed how I cared for myself. Our medical team changed how they managed our care. Onset of condition was rapid, with little time to change our plans. Your health experience during pregnancyPlease check all that apply. I have been/was healthy and comfortable for the whole pregnancy Frequent headaches Persistent discomfort or pain Tension or soreness in specific areas Sensitivity to touch or pressures in specific areas Sensitivity to vibration Numbness or stabbing pain Hypermobility of joints Loss of balance Falls or accidents Nausea, reflux or vomiting Severe viral infection 12-25 weeks Severe viral infection 26-36 weeks Vaginal yeast infection Risk of miscarriage Gestational diabetes Group B strep Severe stress High blood pressure / hypertension Pre-eclampsia Cardiac or circulatory conditions Premature contractions Bleeding during pregnancy Chronic fatigue Bed rest Hospitalization Gut / digestive problems Broken bones Sprained joints Surgery Allergies Auto-immune disorder Respiratory disorders Seizures Trauma Anorexia or bulemia Other health complications Where do/did you experience persistent pain or discomfort? Headache Neck Shoulders Chest or ribs Upper back Middle back Lower back Belly Hips Groin - in front hips & upper legs Pelvic floor, perineum, vagina Sciatic pain (in buttocks and/or down your leg) Legs Feet Other pain Describe other persistent pain or discomfort: How much nausea, reflux or vomiting do/did you experience? Infrequent Mild / Moderate / Manageable Severe When do/did you experience nausea, reflux or vomiting?Note gestational weeks Types of allergies Food Seasonal respiratory Animals & dust mites Responses to medication Other allergy Describe other allergies Number of weeks of miscarriage riskAdd details about premature contractions, including gestational week(s).Bleeding during the pregnancy was infrequent or mild required bed rest Add details about bleeding, including gestational week(s).Add details about any accidents or injuries, including gestational week(s).Briefly describe any other illness you had/have had during pregnancy, including gestational weeks.Add details about other complications, including gestational week(s).Add any other notes about your health during pregnancy.At what gestational week did bedrest begin?Number of weeks on bed restPlease describe why you were hospitalized, including gestational week(s).When did the hospitalization end? During pregnancy Birth Did health conditions for you or your baby change your care of yourself during your pregnancy and/or your birth in any other ways? Yes No Please describe briefly how health condition(s) changed your care of yourself during pregnancy and/or birth.Fill in any additional notes which have not been covered in previous questions. Include gestational week or the general time frame of when you changed your self care.Did health conditions for you or your baby change how your medical care providers managed your pregnancy and/or your birth? Yes No Please describe briefly how health condition(s) changed how your medical care providers managed your care during pregnancy and/or birth.Fill in any additional notes which have not been covered in previous questions. Include gestational week or the general time frame of when medical care & management changed.What is your height?So I can have a birth balls of the proper size for you for the Spinning Babies class. Your nutrition & dietNutrition & DietPlease give a brief, general description of food that you usually eat; or fill in detail below.Day to day diet includes: Protein Whole grains Dairy Beans Nuts Vegetables Fruit Healthy unrefined oils (olive oil, coconut, etc) Vitamin & mineral supplements Omega 3 oils Water Other Protein sources include: Vegetarian protein combinations of whole grain, beans & nuts Dairy Eggs Fish Chicken & fowl Pork, beef and other animal sources Your mind- body health & well-beingMind-body health Often happy Often anxious / stressed Often depressed Describe any major events or stressors in your close family, such as difficult relationships, death, traumatic accident, job loss or other stressors.Have you experienced the loss of a child in pregnancy, birth, infancy or childhood?NoYesHave you felt concerns from prior miscarriage, infant loss or decision to not carry a pregnancy to term? If so, please describe.Prior losses in pregnancy, birth, infancy or childhoodDate of lossAge of childNote if: Miscarriage, lost in childbirth, not carried to term?Brief note on conditions of loss Any additional notes you wish to make about conditions which led to the loss of your childOptional to respondHow has the experience of losing a child affected you?OptionalHow is your sexual life?check any that applyHighly pleasurable & satisfyingSensualCurrently no penetration while recovering from birthPleasant touch and affectionInfrequentNoneFrustrating with little pleasureNumbI feel uptight & constrained in my sexualityTight pelvic floorPainfulPartner is distant or disengagedWhile I don't have a partner, I am satisfied with my sex life.I don't have a partner & don't feel sensual or sexualAny further description of your sexual life that you wish to makeHave you experienced rape or sexual assault?NoYesNot sureDescribe your experience of rape or assault, if you wish.Optional. If you describe your experience, note at what age this happened to you.How has the experience of sexual assault or rape affected you? Or pregnancy or birth?Optional Your self care for well-beingMovement activities Yoga Walking Swimming Dance Workouts Other movement for sport,well-being & pleasure Movement for pregnancy/birth preparation Prenatal yoga Walking Swimming Spinning Babies One Strong Mama Body Ready Method Other movement designed as prenatal activity Other movement activities or detailsAverage amount of time per day for movement Mindfulness practices Meditation Mindfulness based stress reduction Somatic practices - mindfulness in movement Other mind training practices Mindfulness & mind training practices during pregnancy HypnoBabies HypnoBirth Other prenatal mind training practices Somatic & other mind training practicesIntegrative therapies Myofascial therapy Craniosacral therapy Chiropractic Massage Acupuncture Chinese medicine Other integrative therapies Describe other integrative therapiesOptionalChildbirth education classes Hospital based class Independent education Independent childbirth education: Class title & instructorYour birthLength of pregnancyNote gestational weeks & days Baby's birth weight At birth, how was your baby's health? Baby was healthy & thriving at birth Concerns about breathing Concerns about muscle tone - movement Concerns about vocalizations Concerns about heart rate Concerns about color Although there were initial concerns, baby was fine within 5 minutes. Other concerns Any additional notes on special concerns for the baby at birth.Who, as medical providers, attended your birth?Check all that apply CNM midwife Home birth midwife Midwives at freestanding birth center Family practice doctor Obstetrician We chose to have a home birth unattended by medical providers. My baby was born very fast without medical care providers Other Did you have a doula attend your birth?Check all that apply Yes No Planned to have a doula, but she did not make it to the birth Did your doula provide you with assistance after the birth?Make any notes you wish.Note any types integrative therapists who attended your birthNote family members and close friends who attended your birthCheck all that apply Husband Wife Partner My mother Other close family member Close friend Other Planned location of birth Actual location of birth Length of birth overall How did your birth begin? began on its own needed some encouragement was induced with natural methods was induced with help of acupuncture was induced with medical assistance other How did you know that birth had begun on its own? Lost mucus plug Leaking or gushing of water (rupture of membranes) Pressure waves (contractions) began & steadily increased Which home methods did you try to encourage the beginning of birth? Nipple stimulation Lovemaking Walking Hypnosis Spinning Babies activities Body Ready Method activities Movement & positioning Other Which integrative therapies were tried to induce the beginning of birth? Myofascial release bodywork Chiropractic Homeopathy Castor oil Other Which medical methods were tried to induce the beginning of birth? Cervix ripened with prostaglandins (cervidal) Artificial rupture of membranes (breaking water) Foley bulb Pitocin drip to begin labor Other Add any other notes about beginning of birthDuring birth process Slow & steady birth Very fast birth Prolonged birth Pressure waves (contractions) steadily increased over time Pressure waves (contractions) remained the same for long periods Pressure waves (contractions) stopped Very intense pressure waves (contractions) Cervix opened slowly & steadily Cervix open rapidly Cervix stayed at same dilation for a long time Cervix changed when amniotic sac broke & water came out Cervix changed with position changes & movement We did not do cervical checks, but tracked movement of baby descending. Amniotic sac had leaking or gushing of water Amniotic sac remained intact until baby was born Baby was born in amniotic sac Artificial rupture of membranes (staff broke water bag) Medications to slow down labor Medications to sleep Maternal exhaustion Uterine exhaustion Pitocin augmentation How did pitocin augmentation affect the intensity of your contractions?How did pitocin augmentation affect the progress of your birth?Baby during labor and coming out Baby was healthy through labor & birth Baby was well positioned through labor & birth Baby was in a position that made it difficult for him/her to come through the pelvis. Intermittent fetal monitoring Continuous fetal monitoring, able to be mobile Continuous fetal monitoring, confined to bed Baby large for mother’s pelvis Baby remained high for long parts of the birth. Baby remained in the middle of the birth canal for a long time. Baby stuck as s/he came out Cord wrapped around neck Vacuum extraction Forceps Fetal distress Other Complications & procedures at final stages of birth We had no complications or interventions at the end of the final stages of birth Perineum tear 1st degree Perineum tear 2nd degree Perineum tear 3rd degree Perineum tear 4th degree Perineum cut (episiotomy) 1st Degree Perineum cut (episiotomy) 2nd Degree Perineum cut (episiotomy) 3rd Degree Perineum cut (episiotomy) 4rd Degree Difficulty delivering placenta Manual delivery of placenta Hemorrhaging (excessive bleeding) Planned caesarean section surgery Emergency caesarean section surgery Infection -> Mom Infection -> Baby How did you manage the intensity of birth waves or pain? My own images and vision of birth Movement, positions & vocalizing Focus on sensations of baby moving down Water during labor Waterbirth - while pushing baby out Spinning Babies movements Body Ready Method movements & mindfulness Meditation Partner support Doula support HypnoBabies HypnoBirth Hypnosis TENS unit - Transcutaneous Electrical Nerve Stimulation Pharmaceutic pain management-> local cervical pain block Pharmaceutic pain management-> sedatives or tranquilizers Pharmaceutic pain management-> nitrous oxide Pharmaceutic pain management-> narcotic Pharmaceutic pain management-> epidural Pharmaceutic pain management-> spinal block Pharmaceutic pain management-> general anesthesia (C-sec) Pharmaceutic pain management-> local vaginal pain block (for stitches or episiotomy) Pharmaceutic pain management-> other (add details below) Other supports (aromas, massage, etc - add details below) Which activities or support were the most helpful for you? Who was the most helpful to you, in what ways?Add brief note for other pharmaceutic pain managementHow helpful were the drugs provided? Any experiences that affected you?Add brief note for other supports (aromas, massage, etc.)Other major events, or medications & interventions used, if any:Please indicate your feelings about this birthYou can choose from this list, describe in writing below, or both. Joyful, calm, satisfied. I was able to create the birth I envisioned. My birth went well enough, and I am OK about it. Although we had unexpected turns of events, I am satisfied that we made the best decisions possible at the time and drew upon all the resources available to us. I feel numb about the whole experience. Things happened at my birth which bother me, and it’s still hard to think about or talk about. Traumatic birth, very disturbing. I feel like I am breaking down and unable to get past it. Traumatic birth, I still have a lot of physical pain. Traumatic birth, continues to affect my ability to urinate or pass bowel movements. Traumatic birth has affected my relationships with my partner emotionally. Traumatic birth has affected my relationships with my partner sexually. If you wish, write your feelings about this birth:Your newbornPlease check any items that applied to your child at birth and as a newborn: My baby was skin to skin with me continuously from birth for at least 2 hours. Separation from you - in room for initial procedures Separation from you - in next room for initial procedures Separation from you - baby went to NICU Delayed first breath Required resuscitation Other difficulty breathing Required incubation (warmer) Choking Swallowed meconium Blue at birth Red (not pink) at birth Heavy bruising Forceps marks Jaundice Crying excessively Antibiotics given to baby Uneven eye size or placement Uneven ears Misshapen head after 2nd day Sleeping excessively Lethargic / limp Circumcision Surgery Vitamin K Eye ointment Other medications (please describe below) Genetic conditions (please describe below) How long was the separation from you for initial procedures? How long was the separation from you when the baby went to NICU? Please describe genetic conditions:Anything else that you want me to know about your newborn's experience.BreastfeedingAre you breastfeeding or did you ever breastfeed?You may have done it all. Check whatever applies We are currently breastfeeding or attempting to breastfeed. Yes, we are breastfeeding exclusively. Yes, we breastfed for the first six months exclusively. We attempted to breastfeed, but have or had much difficulty Pumping to feed and/or supplement with my breastmilk Trying or tried, but baby not feeding at breast Not currently breastfeeding or pumping Supplementing with donor milk Supplementing with formula Feeding exclusively with formula I have decided to not breastfeed. I do not need support for breastfeeding. How do/did you and your baby experience breastfeeding? Baby and I were able to easily start and maintain breastfeeding Difficulties with latching on Nipple pain Tongue tie or lip tie concerns Problems with sucking Concern about inadequate milk production Poor weight gain Delay in milk coming in (past day 5) Delayed in starting breastfeeding due to C-section Delayed in starting breastfeeding due to health conditions for mom Delayed in starting breastfeeding due to health conditions for baby Delayed in starting breastfeeding due to baby was in NICU Delayed in starting breastfeeding due to too many visitors, not enough sleep, and/or not enough helpers Plugged ducts or engorgement Mastitis Sensitivities or allergic reactions to mother's diet Sensitivities or allergic reactions to formula Gassy Persistent spitting up Projectile vomiting Thrush Any supplementation?You may have done it all! Check whatever applies. Donor milk supplementation Formula supplementation (with breastfeeding) Formula feeding (without breastfeeding) Anything else that you want me to know about your experiences breastfeedingYour nutrition while breastfeedingHas your nutritional intake changed during breastfeeding? I eat mostly the same type of foods as while pregnant. I have changed my diet to help my postpartum recovery. I have eliminated foods as I think my baby is sensitive to some food groups. Anything else that you want me to know about changes in your food intake.Your postpartum recoveryHow has your postpartum experience been physically? I am recovering/have recovered from birth with no physical complications. I have painful or persistent hemorrhoids I have painful or persistently uncomfortable nipples I have pain from stitiches or tearing. Recovery from C-section has been difficult. Other complications of birth & postpartum recovery. How has your postpartum experience been for your emotional wellbeing? I am recovering/have recovered from birth with no emotional complications. I feel a little low at times. I am often depressed or anxious. I am angry about my birth. I am frustrated about not having support that I need. Other emotional challenges of birth & postpartum recovery. Anything else that you want to share about your postpartum experience.Your health historyIf you are a returning client, you may update or skip any questions which you have answered in a prior form.AccidentsPlease list any accidents that you have experienced, along with your age at the time. Also note general treatments that you did to address these.AccidentParts of the body affectedTreatmentAge Chronic aches & painsPlease list any chronic aches & pains that you have experienced, along with your age at the time they began. Also note general treatments that you have done to address these.Chronic conditionParts of the body affectedTreatmentAge Health conditions and treatmentsPlease list any illnesses or previously diagnosed conditions that you has experienced, along with your age at the time. Also note general treatments that you have done to address these.IllnessMedication / TreatmentAge Other Health Condition:Your health care providersIf you are a returning client, you may update or skip any questions which you have answered in a prior form.Types of health care practitioners who provide your care Midwife Obstetrician General medical practitioner (MD, Family doctor) Nurse practitioner or Physician's assistant Medical specialist Physical therapist Pelvic floor therapist Occupational therapist Chiropractor or Osteopath Naturopath doctor Herbalist Homeopath Chinese medicine practitioner or Acupuncturist Bodyworker Other MidwifeName and group practice ObstetricianName and/or group practice Date of last visit MM slash DD slash YYYY Primary care medical providerName or clinical group Date of last visit: Primary care medical provider MM slash DD slash YYYY Medical specialistNote specialization & name of provider or clinical group Date of last visit: Medical specialist MM slash DD slash YYYY Physical therapistName or clinical group Date of last visit: Physical Therapist MM slash DD slash YYYY Pelvic floor therapistName or clinical group Date of last visit: Pelvic floor therapist MM slash DD slash YYYY Occupational TherapistName or clinical group Date of last visit: Occupational Therapist MM slash DD slash YYYY Chiropractor or OsteopathName or clinical group Date of last visit: Chiropractor or Osteopath MM slash DD slash YYYY Naturopath doctorName or clinical group Date of last visit: Naturopath MM slash DD slash YYYY HerbalistName or clinical group Date of last visit: Herbalist MM slash DD slash YYYY HomeopathName or clinical group Date of last visit: Homeopath MM slash DD slash YYYY Chinese medicine practitioner or AcupuncturistName or clinical group Date of last visit: Chinese Medicine Practitioner or Acupuncturist MM slash DD slash YYYY BodyworkerName or clinical group Type of bodywork & condition treated Date of last visit: Bodywork MM slash DD slash YYYY Other practitionersAny other medical or integrative therapy support that has been valuable How did you learn about MamaBebe services?*Check all that apply Prior visit for myself or one of my children Referred by a friend Referred by a family member Referred by my midwife Referred by my doula Referred by my lactation counselor or lactation consultant Referred by my nurse Referred by my childbirth educator Referred by an online forum Referred by an in-person community group Spinning Babies directory Body Ready Method Pro directory ISMETA Somatic practitioners directory Well Connected Twin Cities practitioner directory Google search or SEO search Instagram Facebook Met Catherine at an event Picked up a card for MamaBebe I received a referral from this practitioner or groupPlease note provider or clinical group I received a referral from a community groupPlease note the online or in-person group I met Catherine at: I picked up a card for MamaBebe at: By my signature below, I affirm that Catherine may contact me.* I agree that Catherine may text, email or call me about my concerns and MamaBebe services. I agree that Catherine may email or call me about my concerns and MamaBebe services. By my signature below, I affirm that I have received & read the MamaBebe Client Agreement.* I agree to the terms of receiving services in the MamaBebe Client Agreement By my signature below, I affirm that I have received & read the MamaBebe Integrative Therapies Client Bill of Rights.* I agree to the terms of the MamaBebe Integrative Therapies Client Bill of Rights which includes client rights, full credentials for practitioner Catherine Burns and policies of her practice. Signature* Date* MM slash DD slash YYYY CAPTCHAThank you for filling out the Woman's Intake FormThanks so much. You have completed your intake form! When you click submit, you will receive a copy of your responses by e-mail. I look forward to meeting you - CatherinePhoneThis field is for validation purposes and should be left unchanged.
