Birth Doula Booking Form

Birth Doula Booking Form

Congratulations on your pregnancy! I’m so happy to learn that you are considering doula support for your birth. Please fill out this form to get started.
Client Information
Your Name:

First NameLast Name
Your Date of Birth

MonthDayYear
Date
Estimated Due Date:

MonthDayYear
Date
Your Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Phone Number:
Please enter a valid phone number.
Your Email:
Occupation:
Partner Information
Partner’s Name (if applicable)

First NameLast Name
Relationship with Partner (if applicable)
Partner’s Phone Number (if applicable):
Please enter a valid phone number.
Do you live with your partner?
Will your partner be present at your birth?
Relationship to partner:
Pregnancy Information
Is this your first pregnancy?
Sex of the baby:
How many children do you have?
How many times have you given birth?
Are you expecting multiples (twins, triplets, etc.)?
Have you experienced pre-term birth?
Duration of prior labors?
Planned method of feeding:

BreastfeedingBottleUndecided
Previous birth experiences (check all that apply)

This is my first birthVaginalCesareanVBACMedical InductionElective InductionHospital BirthHome BirthBirth Center BirthWater BirthOther
Have you experienced any of the following pregnancy-related health conditions? (check all that apply)

PreeclampsiaRh IncompatibilityGroup B StrepGestational DiabetesGestational HypertensionSymphysis Pubis DysfunctionHeartburnPicaBack pain/injuryHyperemesis GravidarumSevere insomniaNone of the aboveOther
Have you experienced any of the following health conditions?(check all that apply)

High blood pressureLow blood pressureType 1 diabetesType 2 diabetesAsthmaAnemiaMigrainesUterine FibroidsSeizures/EpilepsyCancerHIVHerpesHPVNone of the aboveOther
Have you experienced any of the following mental healthconditions? (check all that apply)

AnxietyDepressionBipolar DisorderDissociative DisorderPersonality DisorderPost-traumatic stress disorderSchizophreniaObsessive-compulsive disorderAnorexiaBulimiaBinge EatingChronic InsomniaPhobia(s)None of the aboveOther
Are you currently seeing a therapist/counselor?
Are you currently taking any medication? (if so, please list)
Do you have any allergies? (if so, please list)
Have you had any recent injuries, illnesses, or trauma? (if comfortable, please list)
Healthcare Provider Information
Care Provider's Name:

First NameLast Name
Care Provider's Phone Number:
Please enter a valid phone number.
Clinic Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of Provider

MidwifeOBGYNOther
Birthing Location

HospitalBirth CenterHomeOther
Birthing Location Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If planning to give birth at a birth center/hospital, have you taken a tour?
Does your care provider know that you are working with a doula?
Has your care provider given you any medical restrictions? If so, list below.
Are you up-to-date on your prenatal visits?
Is your care provider accommodating of your birth preferences?
Support Information
What comfort measures are you interested in trying during labor?

MassageCold PacksHeat Packs/Heating PadVocalizationShower/BathGuided RelaxationBirthing BallMusic TherapyWalkingDancing/SwayingDim LightingAromatherapyMeditationHerbal SupportAcupressure PointsVisualizationTENS UnitOther
Do you want to create a birth plan?
Will your child(ren) attend your birth? If not, do you have childcare arrangementsmade?
Is there anything you dislike or are sensitive to? (ex. physical touch, essential oils)
Who would you like present at your birth?
What is your idea of my role as a birth doula? What kind of support are you looking for from your birth doula?
Is there anything you would like me to know about this pregnancy, and your needs?
What is your vision for this birth?
What is your preference regarding medical interventions and pain medications?
How do you want your partner to be involved?
Any other questions or concerns?
How did you hear about me?
If you are interested in any of the other services I offer, and would like more information, check the box(es) below:

1-on-1 Prenatal Yoga & Meditation1-on-1 Postpartum Yoga & MeditationBreastfeeding Education/Lactation CounselingPostpartum Meal Prep
Should be Empty:

Birth Doula Booking Form

Client Information

Partner Information

Pregnancy Information

Healthcare Provider Information

Support Information