Intake Form Full Name (as it appears on your Care Card/BC ID) Phone (###) ### #### Email Occupation Are you either pregnant or less than 5 weeks postpartum? If so, you are eligible for MSP covered sessions with a referral. Private pay also available for preconception or postpartum beyond 5 weeks. Yes No How many times have you been pregnant and given birth? Have you had any pregnancy losses? Have you had any complications in your pregnancy or past pregnancies? What is the main reason you are seeking functional maternity counselling? If you are comfortable doing so, please tell me about your diet - for example, are there foods you avoid or are sensitive to? Do you follow any particular diets like vegetarian or keto? Are there any foods that affect your mood? Do you live with any chronic illness or autoimmune condition? How is your sleep? Do you feel like you have a lot of stress in your life? How do you cope with it? Have you ever done the ACE (Adverse Childhood Experience) and Resilience score? Thank you!
