Doula Intake Form

TH&P: Doula.by.Donation

New Client 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 NameLast Name
Gender/Pronouns*
Support Person/Partner's Name

First NameLast Name
Support Person/Partner's Gender/Pronouns
Doctor/ Midwife's / Practice name (Or "Don't Have")*

First NameLast Name
Location for Delivery*
(Home, Hospital or Birth Center)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
example@example.com
Home Phone
Cellphone*
About your baby
Estimated Due Date (Best guess is fine!)*

MonthDayYear
Baby's Gender

BoyGirlUnknownDon't want to know until birth
Baby's name (if chosen already)
Planned Method of Feeding

Breastfeeding/ChestfeedingFormula FeedingBothNot sure but would like more information
About your health
Please state your general health
Do you have any allergies I should be aware of?
Are there any complications with this pregnancy (or past pregnancies)?*
Preperation for Birth
Have you given birth before?*

NoYes,Vaginally onlyYes, Cesarean onlyYes,Vaginally and CesareanI don't want to talk about it
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 related classes you have taken or plan on attending:
Who do you plan to have assist you with your labor?*

PartnerDoulaMother/ Mother-in-LawSisterFriendI don't knowOther
Who do you want present for the delivery (please list)?*
Do you have a birth vision planned?

Yes, It is a final copyYes, but it is a draft and would like some helpNo, I would like some help writing one.No, I have no interest in one.
How do you feel about interventions in labor/delivery?
What type of comfort measures would you like to use in labor?

MindfulnessBreathing PatternsMassageBirth BallWalking, Dancing, SwayingWater (tub/Shower)Hot/Cold TherapyVisualization/ImageryFocal PointsAromatherapyMusicWhat are comfort measuresOther
What is your vision for this birth? *
What are your expectations of me as your doula?*
Do you have a back-up birthing plan?
Do you have any postpartum supports?
Do you have a support network?
Have you had any prior surgeries? (If yes, please describe)
Can you think of any events that may affect your birth experience? (Physical, mental, emotional or spiritual)
Any other questions or concerns?
Signature

Clear
Date*

MonthDayYear
Date
Thank you for trusting us with your care!

You may now schedule at https://calendly.com/trauma-healing-prevention/doula-support-30 and click submit below.
Please enter the date of your scheduled appointment:

MonthDayYear
Date
Should be Empty:

TH&P: Doula.by.Donation