Birth Doula Client Intake
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
Date of birth
-
Month
-
Day
Year
Date
Your Phone Number
*
-
Country Code
-
Area Code
Phone Number
Your Birth Partner's Name
First Name
Last Name
Your Birth Partner's Phone Number
-
Area Code
Phone Number
Your Home Address
*
Street
House Number
City
State / Province
Postal / Zip Code
Your Email
*
example@example.com
Your Birth Partner's Email
example@example.com
Reason for contacting
Confirmed pregnancy/ begin doula support
Infertility
Perinatal depression
Postpartum depression
IVF or IUI
LGBTQIA+ family
Virtual doula support ONLY
Miscarriage/fetal/infant loss support
Homebirth assistant request
VBAC
HBAC
PCOS
Form of payment (newborn photos are self-pay and are not covered by insurance)
Insurance/Va Medicaid
Self pay
Insurance
Aetna
Anthem
Molina
Sentara
United Healthcare
Insurance ID number
Current Pregnancy Information
Estimate Due Date
*
-
Month
-
Day
Year
Date
Baby’s Gender
Girl
Boy
Waiting until birth
I don’t know yet
Doctor/ Midwife's / Practice name
*
Delivery Location
Home
Birth Center
Hospital
I'm not sure yet.
I would like to discuss homebirth options
delivery location( if known):
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. If none type N/A
*
Explain any complications you have had with this pregnancy or any restrictions your caregiver has given you. If none type N/A
*
Pregnancy History
Have you given birth before?
*
No
Yes, Vaginally only
Yes, Cesarean Only
Yes, Vaginally and Cesarean
Do you have a history of miscarriage or infant loss?
Yes
No
Birth Preparation
Have you had a doula before ?
Yes
No
Who do you plan to have assist you with your labor?
*
Partner/Spouse
Doula
Mother/Mother-In-Law
Sister
Friend
Other
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.
Have you written a birth plan?
*
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)
Are there any cultural/religious choices/preferences for your birth that I should know about?
Have you talked about your birth preferences with your caregiver?
How do you feel about interventions in labor/delivery?
What type of pain management would you like to use?
*
Comfort Measures
IV Medication
Epidural
I'm not sure, I would like more information.
Other
What type of comfort measures would you like to use in labor?
*
Distractions
Breathing Patterns
Massage
Birth Ball
Walking, Dancing, Swaying
Water (Tub/Shower)
Hot/Cold Therapy
Visualizations/Imagery
Focal Points
Aromatherapy (Essential Oils)
Music
Other
Please list any questions you have or topics you would like to discuss:
Photography or videography services ?
Birth photography (Free with birth services)
Birth videography add-on $100
Newborn photography add-on $100
Would like more info
No
Submit
Should be Empty: