Doula Client Intake Form

New Client Intake Form

Nicky Dawkins - Full Spectrum Doula
Hello love! Congratulations on your pregnancy! Thank you for taking the time to fill out this form so we can get to know you better and have an idea of how to best support you during your journey through pregnancy, birth and postpartum!
Estimated Due Date

MonthDayYear
Your Full Name

First NameLast Name
Do you have a nickname you prefer?
Your Birthday

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
E-mail
Your Best Contact Number

Area CodePhone Number
Your Partner's Name (if applicable)

First NameLast Name
Your Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Is this your first pregnancy?
If you answered yes above, how long has it been since your last child was born?
Have you ever experienced pregnancy and/or infant loss?
Are you having multiples? (twins, etc)
Doula Services interested in (check all that apply):
Are you aiming to have an all-natural birth without intervention?
Are interested in having a water birth?
Midwife / Doctor - PLEASE COMPLETE. If you're still searching, type N/A

First NameLast Name
Name of practice (if applicable)
Where do you plan to birth? (Hospital / Birthing Center / Home)
Name hospital or birthing center. If you're having a home birth, please type N/A
Hospital or birthing center address - PLEASE COMPLETE

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you currently have health insurance that covers Doula services?
If so, which health insurance do you have?
Please indicate if this is Medicaid or private. If none, please type N/A
About your baby
Baby's name(s) (if known)
Baby's Gender
Planned Method of Feeding
About your health
Please state your general health
Is your pregnancy considered high-risk? If so, why?
Do you have any allergies or sensitivities I should be aware of?
Explain any complications you have had with this pregnancy, any restrictions your caregiver has given you, and any medications you are currently taking.
Any personal, financial, mental health or other issues you would like me to know that may have an impact on our work together?
Preperation for Birth
Have you given birth before?
Are you considering a VBAC (Vaginal birth after c-section)
Have you taken or are you planning on taking any childbirth education classes? If so, what are they and where are you attending them?
Please list any other classes you have taken or plan on attending.
Who do you plan to have assist you with your labor? (Check all that apply)

Other
Who do you want present for the delivery? Please list
Do you have a birth vision planned?
How do you feel about interventions in labor/delivery?
What types of pain management are you open to having during labor?

Other
What type of natural comfort measures would you be open to using in labor?
Will you be keeping your placenta?
IMPORTANT!

If you would like to keep your placenta to assist you with postpartum recovery, you must clear it with you hospital or birthing center prior to delivering. I will be able to assist you will this process.
What is your vision for this birth? Name 3 of your most important things.
What are your expectations of me as your doula?
Any other questions, concerns or things I should know about?
Would you need help with any of the following support services? (check all that apply)
How did you hear about my services?
Should be Empty:

New Client Intake Form

IMPORTANT!