Intake form

Please fill out your details as completely as possible and we will contact you as soon as possible for an intake interview.

First name*

Maiden name*

Street name*

House number*

Zip code*

City*

E-mail address*

Phone Number*

Date of birth*

Number of children?*

Are you already familiar with Bolwerk?*

First day of last menstruation?*

Any comments:

. . Yes, I agree to the privacy & cookie statement.

2 + 5 =

Do you have any questions or doubts? If so, do not hesitate to call or send a message.

“Birth is not only about making babies. Birth is about making Mothers ~ strong, competent, capable mothers who trust themselves and know their inner strength.” – Barbara Katz Rothman