birth doula client intake form.

Hi there!

Please answer this form as detailed as possible. It will take you anywhere from 30 minutes to an hour to answer. This will help me get to know you and your needs a bit better so that I can support you during your pregnancy, labor, the birth of your baby and postnatal period. Only share as much as you feel comfortable sharing. We will go over this during our prenatal visit. Any questions, feel free to call or email me. Thanks!

Pregnant parent's name *
Pregnant parent's name
Pregnant parent's phone number *
Pregnant parent's phone number
Partner's name (if applicable)
Partner's name (if applicable)
Partner's phone number (if applicable)
Partner's phone number (if applicable)
Estimated Due Date *
Estimated Due Date
(physically, emotionally/spiritually, mentally, logistically, etc.)
Have you outlined your birth preferences?
This is refers to your "birth plan." I prefer saying preferences because labor is unpredictable and calls for flexibility!
(items to bring, desired ambiance [lights, music, photos], snacks, etc.)
(water, massage, visualization, walking, breathing, position changes, encouragement, pain medication, etc.)
Would you like to your birth to be captured?
Note: please be sure to provide the camera to be used (can be cell phone) and to check with your care provider if this is okay if taking place in hospital or birth center.
(e.g., vaginal exams, rupturing of the membranes, IV, etc.)
Your plan/interest for infant feeding:
(childbirth education, prenatal yoga, massage, acupuncture, lactation support, etc.)