Postpartum Client Intake Form
Please answer all questions to the best of your ability. If there are questions you don’t want to answer, please remember you do not have to. The information you give will help me provide more comprehensive services to you. I respect your right to privacy and can assure that your answers will be held in the strictest confidence. With your permission, I may potentially share this intake form with my backup doula should they need to support you in my absence.
Contact Information
Full Name:
*
First Name
Last Name
Partner's Name (if applicable):
First Name
Last Name
Home Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
-
Area Code
Phone Number
Partner's Phone Number (if applicable):
-
Area Code
Phone Number
E-Mail Address:
*
example@example.com
Preferred Method(s) of Communication:
Phone
Text
Email
Your Pregnancy
Estimated Due Date:
*
-
Month
-
Day
Year
Date
Your OB / Midwife:
(name and phone number in case of emergency)
Your PCP and/or Therapist:
(name and phone number in case of emergency)
Baby's Pediatrician:
(name and telephone number in case of emergency)
Planned Place of Birth:
Do you intend to use a birth doula?
Yes
No
Have you discussed any questions, concerns, or wishes with your OB/Midwife? If so, are you comfortable with the responses you receive?
Any complications / high-risk factors during this pregnancy and/or any general past concerns I should know about?
(scheduled cesarean section, diabetes, preeclampsia, high BP, depression, anxiety, history of substance abuse, etc.)
Have you taken any childbirth, newborn care or breastfeeding classes? If not, do you plan to?
Have you ever breastfed before? Any issues?
About You
Age:
Profession / Occupation:
Any dietary restrictions or modified diet?
What do you find helpful during times of stress?
(solitude, companionship, extra rest, specific forms of self-care, etc.)
About Your Family
Who else lives in your household?
(Names and ages. Animals included!)
Is there anything I should know about your family?
(medical needs, developmental needs, food allergies, etc.)
Working Together
What are your postpartum support plans (if any)?
(maternity/paternity leave plans, sibling care, additional support people, etc.)
Do you (and your partner) have any specific concerns regarding the postpartum period?
(newborn care, breastfeeding, pain management, etc.)
What are your expectations of having a postpartum doula? What do you envision needing the most support with?
Are there any cultural or religious traditions/beliefs you wish to honor during the postpartum period that I should be aware of?
Do you wish for the doula to wear a mask while in your home?
(Your doula is fully vaccinated)
Is there any additional information that you would like me to know so that I can better support you?
How did you hear about us?
*
Doulamatch.net
Referral / Word of Mouth
Google search
Internet
Other
SUBMIT
Should be Empty: