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.

Name (pregnant person)*
First Last
Date of Birth*
MM slash DD slash YYYY
Partner's Name
First Last
First day of Last Menstrual Period*
MM slash DD slash YYYY
Estimated Due Date*
MM slash DD slash YYYY
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*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Email*
How did you hear about us?*
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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!
Ariana Brookshier

Brooke was my midwife for my second pregnancy and I am beyond grateful for her thoughtful care throughout the whole process. She took the time at each prenatal appointment to go over any questions or concerns that I may have. She never rushed the appointments and addressed each concern with patience and care. It is extremely evident that Brooke has a huge heart for pregnant mamas and their babies. I have never experienced care like hers from another health care provider. Brooke’s calm spirit was extremely comforting at my home birth. I felt completely safe knowing her extensive experience. Feeling safe was a big concern for me, but I never doubted my safety or my baby’s while under Brooke’s care. Brigid, Brooke’s assistant, was also apart of every prenatal appointment and a big part of my birth. She is extremely patient and nurturing. They made an amazing team and I will miss seeing them both on a regular basis. One thing that really stood out to me was Brooke and Brigid’s desire to get to know me and my family on a personal level before our home birth. I found this to be so valuable and it made me feel extremely comfortable inviting them in to our home. I will shout Brooke’s praises from the rooftops forever. If I have another baby, there is no question that I will want Brooke as my midwife. - 7/06/2024
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Ariana Brookshier

- 7/06/2024

Brooke was my midwife for my second pregnancy and I am beyond grateful for her thoughtful care throughout the whole process. She took the time at each prenatal appointment to go over any questions or concerns that I may have. She never rushed the appointments and addressed each concern with patience and care. It is extremely evident that Brooke has a huge heart for pregnant mamas and their babies. I have never experienced care like hers from another health care provider. Brooke’s calm spirit was extremely comforting at my home birth. I felt completely safe knowing her extensive experience. Feeling safe was a big concern for me, but I never doubted my safety or my baby’s while under Brooke’s care. Brigid, Brooke’s assistant, was also apart of every prenatal appointment and a big part of my birth. She is extremely patient and nurturing. They made an amazing team and I will miss seeing them both on a regular basis. One thing that really stood out to me was Brooke and Brigid’s desire to get to know me and my family on a personal level before our home birth. I found this to be so valuable and it made me feel extremely comfortable inviting them in to our home. I will shout Brooke’s praises from the rooftops forever. If I have another baby, there is no question that I will want Brooke as my midwife.