Homebirth Consultation Questionaire

Planning your first home birth?
Start by filling out this quick form so we can make sure home birth is the best fit for you and your baby.

"*" indicates required fields

Name (pregnant person)*

First Last

Date of Birth*

Partner's Name

First Last

First day of Last Menstrual Period*

Estimated Due Date*

How many weeks pregnant are you (or pre-conception)?*

Have you given birth before? (Specify # of each vaginal & cesarean)*

Any medical conditions?*

Any pregnancy complications in this or previous pregnancies? (If yes, explain)*

Have seen another pregnancy provider? (If yes, who)*

Insurance and type (PPO, HMO, HSA)?*

Address*

(Needed to insure you are within our travel range)

Street Address City ZIP Code

Phone*

Email*

When is the best time for a phone call to discuss your in person consultation?*

Add any questions or concerns you would like addressed.

How did you hear about us?*

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Tiffany Callaway

Brooke Ray and her team were amazing. They were professional, kind, friendly, and knowledgeable. I did not have to worry about their care throughout the process. Wonderful experience with this team. I would highly recommend. I’m - 3/25/2025
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Tiffany Callaway

- 3/25/2025

Brooke Ray and her team were amazing. They were professional, kind, friendly, and knowledgeable. I did not have to worry about their care throughout the process. Wonderful experience with this team. I would highly recommend. I’m
Sey Pitton

The whole time I was under Brooke’s care, I felt so deeply taken care of. Physically, mentally, emotionally. This was my first homebirth, and I am so glad that I entrusted the birth of my baby in Brooke’s and Brigid’s hands. I got the sense that they truly care about what you want and making that happen while making sure everybody involved is safe. They went the extra mile to make sure they did the best they can do for me and my baby. I labored a lot longer than we expected, but they made sure that both my baby and I were safe, and it turned out to be the beautiful homebirth that I always wanted. I highly recommend Brooke Ray to any mom and family who want a homebirth. - 11/26/2024
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Sey Pitton

- 11/26/2024

The whole time I was under Brooke’s care, I felt so deeply taken care of. Physically, mentally, emotionally. This was my first homebirth, and I am so glad that I entrusted the birth of my baby in Brooke’s and Brigid’s hands. I got the sense that they truly care about what you want and making that happen while making sure everybody involved is safe. They went the extra mile to make sure they did the best they can do for me and my baby. I labored a lot longer than we expected, but they made sure that both my baby and I were safe, and it turned out to be the beautiful homebirth that I always wanted. I highly recommend Brooke Ray to any mom and family who want a homebirth.
Jessica Hickey

We are so grateful to have had Brooke supporting us through our fourth pregnancy & first home birth. Brooke and her team were amazing— they are super friendly and professional, and made me feel very comfortable and cared for throughout my pregnancy, the birth, and postpartum. If you are looking for a midwife, I highly recommend Brooke! - 7/25/2024
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Jessica Hickey

- 7/25/2024

We are so grateful to have had Brooke supporting us through our fourth pregnancy & first home birth. Brooke and her team were amazing— they are super friendly and professional, and made me feel very comfortable and cared for throughout my pregnancy, the birth, and postpartum. If you are looking for a midwife, I highly recommend Brooke!