Doula Intake Form

Yetu Village Birth Collective

New Client Intake Form: Birth Doula
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 we can best support you during your pregnancy, birth, and postpartum!
Birthing Person's Name*

First NameLast NamePronouns
Partner/Suport Person's Name

First NameLast NamePronouns
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Phone*

Area CodePhone Number
Partner or Support Person's Phone

Area CodePhone Number
Emergency Contact*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship*
Do you have any pets?

Yes, dogsYes, catsYes, dogs and catsNoOther
About your baby
Estimated Due Date*

MonthDayYear
Baby's Sex

MaleFemaleUnknown
Baby's name
Planned Method of Feeding*

BreastfeedingFormula FeedingBothNot sure but would like more information
Is this your first baby?*

YesNoRainbow baby
Other children's names & ages
About Your Birth Location
Doctor/ Midwife Name

First NameLast Name
Location*

HomeHospitalBirthing CenterOther
Birth Location Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
About Your Health
Do you have any medical conditions we should know about?*

YesNoOther
Explain any complications you have had with this pregnancy, any restrictions your caregiver has given you, and any medications you are currently taking.*
Preperation for Birth
Have you given birth before?*

NoYes,Vaginally onlyYes, Cesarean onlyYes,Vaginally and Cesarean
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.
What is your planned labor method?*

SpontanousPlanned CesareanPlanned induction
Who do you want present for the delivery?*
Do you have birth wishes planned?

Yes, It is a final copyYes, but it is a draft and would like some helpNo, I would like some help writing one.No, I have no interest in one.
How do you feel about interventions in labor/delivery?
What type of pain management are you looking to have? *

Comfort MeasuresIV MedicationEpiduralOther
What type of comfort measures would you like to use in labor?

DistractionsBreathing PatternsMassageBirth BallWalking, Dancing, SwayingWater (tub/Shower)Hot/Cold TherapyVisualization/ImageryFocal PointsAromatherapyMusic
What is your vision for this birth? *
What are your expectations of Yetu Village as your doula?*
Are you interested in having a photographer?

YesNo
Any other questions or concerns?
By clicking yes, you understand that all information provided is correct. Any information shared with the Yetu Village team is kept confidential.*

YesNo
Should be Empty:

Yetu Village Birth Collective