Preparing for The Fourth Trimester Questionnaire

This form is to help me get to know you and your family a bit better. There is no pressure to share anything you don’t want to, and all questions are optional except for contact information.

All responses and information shared during our discussions are strictly confidential and all paperwork including this completed form are kept in accordance with GDPR regulations. Please complete and return this form a minimum of 24 hours before your first session to enable me time to prepare for our time together. If you experience any issues with this form, please email me at info@themilkhub.co.uk

Your name *

First

Last

What are your preferred pronouns for yourself and your family?

Your email address *

Your telephone number *

Your address *

What is the name of your partner/supporter?

First

Last

What is your relationship to your named partner/supporter?

E.g. husband, wife, partner, friend, parent, etc.

Will your partner/supporter be attending our session too?

If you/your partner have older children or step children, please let me know their names and ages.

What is your expected due date?

How many weeks pregnant are you at the time of completing the form?

Is your pregnancy considered high risk?

If your pregnancy is considered high risk, please share as much detail as you would like to around the reason for this clarification.

This information helps shape my support. For example, if you are at high risk for pre-term labour, the strategies owe discuss may be different from someone with gestational diabetes.

Do you have any thoughts around how you plan to feed your baby/babies?

i.e. breast/chest feeding, formula feeding, expressing or combination feeding.

Is there anything about feeding your baby that you are particularly worried about or looking forward to?

If you have older children, please share a little information about your previous feeding experiences.

If this is your first baby, feel free to skip this section.

Are there any specific anxieties, concerns or feelings you are experiencing at the moment which may be helpful to explore during our session?

Are there any other services or professionals you as a family are currently working with? *

For example; Early Help, Perinatal Mental Health, Childrens Social Care, Home Start, Your Family, Infant Feeding Team etc.

Are there any health concerns for you and/or your baby/babies? *

E.g. Previous breast surgery, fertility or hormonal concerns, heart conditions, diabetes, tongue-tie or other oral concerns.

Is there anything else you'd like to share with us?

Thank you for taking the time to complete the questionnaire, I know it is quite long! The more detail I have prior to the session means the more time we can focus on support and information for you.

By completing and submitting this questionnaire you are giving permission for The Milk Hub to collect and process the above information including any personal information as defined under GDPR regulations, and in line with both our legitimate interests. All information you supply is held in the strictest confidence and not shared with any third parties without your consent. The only exception to this is if we are required to disclose information to another agency or service in line with a safeguarding concern. Completing and submitting this questionnaire also acknowledges that you accept the Privacy Notice, Terms and Conditions and Safeguarding Policy listed on The Milk Hub website. *

I agree

Preparing for The Fourth Trimester Questionnaire

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