Congratulations! Thank you for considering me to walk through such an intimate time in your family's life. I cannot wait to connect and potentially start our bond as doula and mama (mama to be). A great first step is to ensure that we are the right fit for one another. By taking some time to fill out this intake form, this will help me know if and how I can best assist you during pregnancy, birth, and postpartum. Thanks in advance and I look forward to getting to know you!
Please fill out the information below as best as you can.
Your Name
*
First Name
Last Name
Date of birth
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Month
-
Day
Year
Date
Your Phone Number
*
-
Area Code
Phone Number
Your Birth Partners Name
First Name
Last Name
Your Birth Partner's Phone Number
-
Area Code
Phone Number
Your Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Email
*
example@example.com
Your Birth Partner's Email
example@example.com
About you + Your Pregnancy
Estimate Due Date
*
-
Year
-
Month
Day
Date
Doctor/ Midwife's / Practice name
*
Delivery Location
*
Home, Birth Center, Hospital
Do you have insurance? If yes, please share who your insurance is with.
Planned Method Of Feeding
Breastfeeding
Formula Feeding
Combination
Not sure but I would like more information
Are you currently experiencing any specific health or other concerns that affect this pregnancy? As with all of your information, anything you share will be kept confidential.
*
Explain any complications you have had with this pregnancy or any restrictions your caregiver has given you.
*
Any allergies?
Pregnancy History
Have you given birth before?
*
No
Yes, Vaginally only
Yes, Cesarean Only
Yes, Vaginally and Cesarean
Any history of miscarriage or infant loss?
Please Select
Yes
No
Have you taken or are you planning on taking any childbirth education classes?
*
In 5 words, please describe how you would like to FEEL and how you would like your birthing space to feel? (ex: calm, peaceful, energized, happy)
What is your vision for this birth?
*
Are you a trauma survivor? If yes, are there any triggers I should be made aware of and are you comfortable with discussing them?
Anything else I should know in order to better support you?
What is your faith/religion if any?
I am a doula who holds her Christian values very closely, but I do not impose my beliefs. Is this something that you are okay with?
I lovingly welcome mamas and future mamas of every race. However, I want to acknowledge that I am a black woman who advocates for for all women, but specifically black women, who currently experience the highest maternal mortality rate from childbirth. (Black women are 3-4 times more likely to die during or after childbirth than white women." CDC Pregnancy MSS). Can you acknowledge that this is true even if you are not the same race?
Yes, I can.
No, I cannot.
Submit
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