New Client Questionnaire
Thank you for taking the time to answer these questions. This questionnaire is to help me get to know you better and how to best serve you! Everything you share with me is 100% confidential and I will never share any of your information or our talks, visits, photographs, or birth info without your Express permission. Your body, baby, and pregnancy is strictly your own and my job is to help you explore this experience, empower you, advocate for you, protect your sacred birthing space, and give you ideas to achieve the birth you desire most. The questions in this document may not all apply to you so just answer the ones that do. You are always entitled to change your mind and this is not a binding contract by any means. You do not need to feel obligated to share anything with me that you are not comfortable doing. I promise first and foremost to always respect you and your family and you have the right to change your mind at any time no questions asked. Along your journey the answers may change and I will be keeping in touch with you to stay up to date and help you along should you choose to hire me. The meaning of the word doula is “woman servant”. I provide hands on practical support in all stages of your journey to parenthood. I also provide information and knowledge to help you make educated decisions. I provide classes to help you try out and know various pain management and coping techniques for labor and birth. I provide emotional support to help you through each stage of childbearing. My job is not to take the place of your partner but rather an extra set of helping hands to lovingly help all parties achieve the best experience possible. I provide support in fertility planning, pregnancy,labor and delivery, postpartum and breastfeeding, placenta encapsulation,freezer meal prep (for postpartum meals), sexual abuse survivor, and VBAC. Not all of these may apply to you and you may not want or need all of these services do not feel obligated to utilize them all. You know yourself best and this questionnaire will help you and I decide if we are a good fit and what types of support you will need. I believe every woman that wants a doula should have one and she should not worry about the ability to afford one. In the case you want a doula and feel you cannot afford one, I am willing to do a payment plan if necessary. Every woman is inherently powerful and deserves the right doula to help her family achieve the best experience possible.
Partner's Name (if applicable)
Partner's Phone Number
Street Address Line 2
State / Province
Postal / Zip Code
Planned Place of Birth
Hospital or Birth Center Location
Is your Care Provider :
Street Address Line 2
State / Province
Postal / Zip Code
Have you shared with your provider that you will be utilizing a doula?
How Many Previous Pregnancies?
How Many Live Births?
Do you feel any previous pregnancies or births will affect your current journey?
How do you feel your current pregnancy is going?
Do you feel safe in your home?
If not, how can I help?
Are you expecting multiples?
Do you intend to find out the gender?
Does baby have a name yet?
Who all will be on your birth team?
In a few short sentences, summarize your perfect birth:
Do you have a written birth plan/preferences?
If not, would you like help drafting one?
Do you plan on using medication in labor, such as epidural or spinal block?
Do any of these methods of pain relief sound appealing to you? (choose all that apply)
In a stressful or scary situation, how do you react physically?
How do you find you best cope with pain? what methods are helpful to you?
In the event of an emergency, what would you like me to do? Is there anyone specifically you would need me to contact and notify?
Do you have any religious preferences
Do you have any unique cultural or religious practices that you would like to include in your pregnancy, birth, or postpartum period?
Any additional information you think will affect your pregnancy or birth? Anything else you want me to be aware of for your pregnancy, labor,and birth?
What would you like ME to do for you during labor? How can I best support you?
Note: One postpartum visit is included within 1 week in all of my labor and birth services whether or not you require my assistance as an official postpartum doula or not. Reason being, postpartum is a very important part of the birth process and it is important to have extra hands helping during the closing of one chapter and the beginning of a whole new one. The phrase “it takes a village” rings true with wisdom.
Do you plan on breastfeeding, formula feeding, exclusively pump, or combination?
Do you want assistance with breastfeeding?
Do you want information and support on postpartum recovery?
Would you like help with: (choose all that apply)
Would you like information on: (choose all that apply)
Basic baby care (diapering, feeding, bathing, etc.)
Car seat Safety
Postpartum Freezer Meals
Would you like postpartum visits?
If yes, approximately how long would you want postpartum service for?
Are there any other ways that I can help during your postpartum period?
What is placenta encapsulation? Placental encapsulation is the practice of ingesting the placenta after it has been steamed, dehydrated, ground, and placed into pills.Traditionally, this is taken by the mother and is believed to impart numerous health benefits. It is frequently taken shortly after giving birth, during a woman’s menstrual period, or during menopause with the belief that it helps counter some of the symptoms of menopause.
Do you understand the process of placenta encapsulation?
Send me Info
Do you want more information on the benefits and risks of placenta encapsulation?
Do you have any blood borne pathogens that you know of? ( this does not automatically disqualify you dependent on the pathogen)
Would you like information on any of these types of placenta methods? (choose all that apply)
Both (half capsules, half chocolates)
Liquid Tincture ( add on only)
Salve (add on only)
Are there any specific herbs that you would like to discuss to add to your placenta encapsulation?
Would you like information on any herbs, herbal tinctures and salves?
Postpartum Freezer Meal Prep
The postpartum period can be a rough recovery for some. I offer my time to help prepare meals or show you how to prepare meals for that recovery period. Freezer meals, meal prep or simply sending recipes are ways I can help.
Would you be interested in learning more about freezer meal prepping and how it can benefit you?
Are there any diet restriction or allergies?
Would you like:
To learn to meal prep
Have me prep for you
me to send recipes and videos
all of the above
There are classes available either in person or online, to help you get or feel a little more prepared.
Which classes would you like more information on? (choose all that apply)
Postpartum needs and recovery
Any other information you would like that was not covered?
Any Questions you have for me?
Any concerns or fears you have that you would like to talk about or work through?
Any concerns or fears your partner has that you would like to talk about or work through?
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