Ora Doula Services Intake Form

ORA DOULA SERVICES

New Client Intake Form
Your Name *

First Name Last Name
Your Partner's Name

First Name Last Name
Doctor/ Midwife's / Practice name *

Name Practice
Delivery Location *
Home Address (for prenatal and postpartum appointments)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail *
Phone *

Area Code Phone Number
The birth package I have selected is:

Basic Birth Package: 2 prenatal appointments, labor & birth support, 1 brief postpartum appointment Nourishing Birth Package: 2 prenatal appointments, labor & birth support, nourishing postpartum appointment with meal prepared by Cocina Cura, herbal bath if birth was vaginal, 2-3 hours of postpartum doula services
About your baby
Estimated Due Date *

Month Day Year
Baby's Gender

Boy Girl Unknown
Baby's name (if known)
Planned Method of Feeding

Breastfeeding Formula Feeding Both Not sure but would like more information
About your health
Please state your general health
Do you have any allergies 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. *
Preperation for Birth
Have you given birth before? *

No Yes, Vaginally only Yes, Cesarean only Yes, 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.
Who do you plan to have assist you with your labor? *

Partner Doula Mother/ Mother-in-Law Sister Friend
Who do you want present for the delivery? *
How do you feel about interventions in labor/delivery?
What type of pain management are you looking to have? *

Comfort Measures IV Medication Epidural
What type of comfort measures would you like to use in labor?

Distractions Breathing Patterns Massage Birth Ball Walking, Dancing, Swaying Water (tub/shower) Visualization/Imagery Birth Affirmations Aromatherapy Music Rebozo I don't know yet!
What is your vision for this birth? *
What are your expectations of me as your doula? *
Any other questions or concerns?
Payment Method

I will pay by check. I will pay with cash. I will pay via PayPal. I will pay with HSA/FSA. I am interested in a payment plan. I would like to contribute to the scholarship fund for low income clients. I am a Journey Birth & Wellness Client
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ORA DOULA SERVICES