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New Client Intake Form
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.
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Partner's Name (if applicable)
First Name
Last Name
Partner's Phone Number
-
Area Code
Phone Number
Partner's Email
example@example.com
Due Date
*
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Planned Place of Birth
*
Hospital
Birth Center
Home
Hospital or Birth Center Location
Providers Name
Is your Care Provider :
An OB
A Midwife
Address for Place of Birth
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you shared with your provider that you will be utilizing a doula?
Yes
No
How Many Previous Pregnancies?
How Many Live Births?
Any Miscarriages?
Do you feel any previous pregnancies or births will affect your current journey?
Yes
No
Maybe
How do you feel your current pregnancy is going?
Do you feel safe in your home?
Yes
No
If not, how can I help?
Are you expecting multiples?
Do you intend to find out the gender?
Its ok to want to keep it a secret.
Does baby have a name yet?
Only share if you want.
Who all will be on your birth team?
It is important to have your birth team all on the same page.
In a few short sentences, summarize your perfect birth:
I want to help you achieve your ideal birth!
Do you have a written birth plan/preferences?
If not, would you like help drafting one?
Yes
No
Maybe
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)
Massage
Heat/Cold Therapy
Visualization/Relaxation
Meditation/Prayer
Vocalization/Singing/Etc.
Breathing Techniques
Hypnobirthing/Hypnobabies
Rebozo
Counter Pressure
Yoga
Essential Oils/Aromatherapy
In a stressful or scary situation, how do you react physically?
Are there any triggers or traumas that you are concerned may come up throughout pregnancy or labor?
This is confidential, this is for me to know how to best support you.
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?
Do you plan on breastfeeding, formula feeding, exclusively pump, or combination?
Would you like information on: (choose all that apply)
Basic baby care (diapering, feeding, bathing, etc.)
Safe Sleep
Car seat Safety
Cloth Diapers
Circumcision
Vaccines
Postpartum Depression/Anxiety
Postpartum Freezer Meal Services
Placenta Preparation Services
Postpartum Support
Lactation Support
Trauma Support
Homebirth
VBAC
Energy Healing/Cleanse to help with Fears/Traumas
Childbirth Education Classes
Herbs/Holistic Remedies
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?
List any, even the smallest one. Sometimes having information can ease that fear.
Any concerns or fears your partner has that you would like to talk about or work through?
I am here for both you and partner, to give you both information and support.
Submit
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