New Client Intake Form

New Client Intake Form

Congratulations on this new journey! Let us know a little more about what you are looking for and how we can help you.
We believe in providing clear and upfront information about our payment options. While we currently do not bill insurance companies directly, we understand that managing the costs of postpartum and family support is important. To make our services accessible, we offer a variety of flexible payment methods:
- Payment Plan: We can create customized payment plans to align with your budget and needs. For detailed information on our pricing and payment plan structures, please request our pricing sheet via email.
- HSA/FSA: We gladly accept payments from your Health Savings Account (HSA) or Flexible Spending Account (FSA).
- Afterpay: For added convenience, we offer Afterpay, allowing you to spread your payments over manageable installments.
- Superbill for Insurance Reimbursement: We provide a comprehensive superbill that you can submit to your insurance provider for potential reimbursement. Please note that reimbursement is subject to your insurance policy's terms and conditions.
- Gift Cards: To make it easy for family and friends to contribute to your support, we offer gift cards that can be added to your registration.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Partner's/Spouse's Name (if applicable)

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Estimated due date or baby's date of birth.*

MonthDayYear
Date
Any pets in the home? If so, please specify.
Check all that you are interested in.*

Birth DoulaDaytime Postpartum DoulaOvernight Postpartum DoulaSibling DoulaLactation SupportHolistic Fertility DoulaPlacenta EncapsulationPartner Guidance SessionTrauma & Emotional Healing Through Guided MeditationChildbirth ClassesNewborn Care Informative Classes
If you selected birth support, where is your planned place of birth?

HospitalHomeBirth CenterUnsure, would like some guidance.
How many weeks or months of postpartum support are you anticipating needing?
We typically start with a minimum of 20 hours for daytime and 24 hours for overnight support. If it helps, we can begin with those minimums and then add more hours later on if you need them.
Is there anything specific you are looking for information on?*
Specify your concerns, be as detailed as possible so we know which areas to focus our support on. *
Do you have any history of anxiety/depression?

YesNoNot sure
Any important information you would like to share with us, that you think would affect your journey? *
We offer emotional and educational guidance and can help through any fears or concerns that can come up for you.
What prompted you to seek doula care? *
What are your expectations from our services or your doula? *
What are you looking for in a doula? *
How did you hear about us?
Please share their name and email if you are able to so we can send a thank you!
Get your agency process questions answered quickly! A 5–10-minute call with our intake coordinator will clarify everything. You will still have a meet and greet scheduled. Or, schedule the meet and greet directly. Which do you prefer?*

Schedule an intake call first.Schedule the meet and greet directly.
Do you have any specific questions for the intake team?
This will help make the call go quickly
Should be Empty: