SS 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 may best support you during your pregnancy and birth.

Upon receipt of this form, Kelsie will contact you within 72 hours to schedule a short in-person meeting to review the information before proceeding with contract signing. All information shared will be kept confidential - this form is HIPAA compliant.
Your Name

First NameLast Name
Your Phone Number

Area CodePhone Number
Your Email
example@example.com
Your Birth Date

MonthDayYear
Date
Your Birth Partners Name

First NameLast Name
Your Birth Partner's Phone Number

Area CodePhone Number
Your Birth Partner's Email
example@example.com
Your Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Information

If planning to pay out of pocket for doula services, please fill "N/A" in req'd fields and select today's date.
If seeking to have Tricare cover doula services, please select the appropriate field for who is the Sponsor.
Do you have any other health insurance?
Sponsor's Name

First NameLast Name
Your DBN - DoD Benefits Number (11-digit benefits number on back of ID) for insurance benefits & eligibility verification.
Sponsor's Social Security Number (This information is required for insurance benefits & eligibility verification.)
Current Pregnancy Information
Estimate Due Date

MonthDayYear
Date
Doctor / Midwife's Name
Delivery Location
CCMH, SWMC, DRH, WFBWC, OU, etc.
Planned Method Of Feeding
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?
Any history of miscarriage or infant loss?
If you have other children, please tell me about each pregnancy and birth experience. Please include: gestation at birth, how your labor(s) began and progressed, and if you experienced any complications. If this does not apply to you, please put N/A.
Any history of sexually transmitted infections/diseases? Abnormal paps? Sexual/other abuse? Postpartum mood disorders? Other communicable illnesses/diseases?
Do you have any other medical conditions I should be aware of?
Any additional information you feel I should know?
Birth Prep
In order to prepare for an informed birth experience, it is strongly suggested to take a childbirth education class with Kelsie Terry Birth Services, LLC or a hospital offered course.
Please list any other classes you have taken or plan on attending.
Who do you plan to have assist you with your labor?

Other
Who do you want present for your labor and delivery? (Kelsie MUST be present for the delivery in order for the services to be covered by Tricare.)
Do you have a birth vision (plan/preferences sheet)?
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, informed)
Have you talked about your birth preferences with your birth partner / care provider? 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?
On a scale of 0-10 (0 being you know you want NO pain management and 10 being you know you definitely want pain management), how do you feel about receiving pain management in labor?
What type of pain management are you looking to use?

Other
What type of comfort measures would you like to use in labor?
What is your vision / goals for this birth?
What are your fears surrounding birth? Have you discussed them with your partner and/or care provider?
Anything else I should know in order to better support you?
How did you hear about Kelsie Terry Birth Services, LLC?
If referred by someone, please share their name.
Should be Empty:

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 may best support you during your pregnancy and birth.

Insurance Information

Current Pregnancy Information

Pregnancy History

Birth Prep