ORA DOULA SERVICES
New Client Intake Form
Your Name
*
First Name
Last Name
Your date of birth
*
-
Month
-
Day
Year
Date
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
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
E-mail
*
Add me to the monthly Ora Doula Services email newsletter:
Yes please!
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
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2029
2028
2027
2026
2025
2024
2023
2022
2021
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
Other
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
Other
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.
Submit
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