New Moon Doula Care Intake Form

Congratulations on your pregnancy! Thank you for taking the time to fill out this form so I can get to know you better and have an idea of how I can best support you during your pregnancy, birth and postpartum.
Your Name *

First Name Last Name
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
Current Pregnancy Information
Estimate Due Date *

Year Month Day
Date
Doctor/ Midwife's / Practice name *
Delivery Location *
Home, Birth Center, Hospital
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. *
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?
Birth Prep
Have you taken or are you planning on taking any childbirth education classes? *
Please list any other classes you have taken or plan on attending.
Who do you plan to have assist you with your labor? *

Partner/Spouse Doula Mother/Mother-In-Law Sister Friend
Who do you want present for the delivery? *
Do you have a birth vision planned? *

Yes, it is a final copy. Yes, but it is a draft and I would like some help. No, I would like like help writing one. No, I have no interest in one.
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)
Have you talked about your birth preferences with your caregiver? Are there any cultural/religious choices/preferences for your birth that I should know about?
How do you feel about interventions in labor/delivery? How would you like your doula to respond if you are requesting pain medication?
What type of pain management are you looking to use? *

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

Distractions Breathing Patterns Hypnosis Mediation Massage Birth Ball Walking, Dancing, Swaying Water (Tub/Shower) Hot/Cold Therapy Visualizations/Imagery Focal Points Aromatherapy (Essential Oils) Music
What is your vision for this birth? *
Anything else I should know in order to better support you?
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Congratulations on your pregnancy! Thank you for taking the time to fill out this form so I can get to know you better and have an idea of how I can best support you during your pregnancy, birth and postpartum.

Current Pregnancy Information

Pregnancy History

Birth Prep