D. Unique Doula Intake Form

D. Unique Doula Intake Form
Peace mama!
Welcome to your birth journey.
Please answer these questions to the best of your ability. Any additional questions can be discussed during our meeting. Speak with you soon.
Basic Information
Name

First NameLast Name
Date Of Birth
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
List What Doula Services Are You Interested In or your doula needs. If you don’t know, describe as best as you can.
What was the first day of your last Menstrual period?
Guess Date?
If you know the gender or name, state it here.
What is the name of your provider? (OBGYN, Midwife, or N/A)
What is your relationship status?
How is your nutrition like?
How much water do you drink daily?
What is your sleep schedule like?
How often do you exercise?
Lets Get Personal
Why do you want me to be your doula?
Do you have support from others during this pregnancy?
How many times have you been pregnant?
Any Miscarriages or history of stillbirth?
Did you carry those pregnancies to greater than 37 weeks?
How old are they? (Disregard if you are a first time parent)
How many living children do you have at home?
How do you feel emotionally about this pregnancy?
Have you connected with any support groups?
Are you currently doing anything in preparation for your pregnancy? (i.e. childbirth classes, prenatal yoga, fertility counseling, childbirth/ pregnancy books, watching birth videos) (i.e. childbirth classes, prenatal yoga, fertility counseling, childbirth/pregnancy books, watching birth videos)
Medical Intake

If you are not sure, leave blank.
List Allergies.
Blood Type
Are you having any pregnancy symptoms? (Nausea/Vomiting, pelvic ligament pain, frequent urination, uncontrolled headaches, swelling on the legs, arms or face, back pain, accidental leaking, yeast infections, spotting/ bleeding, recent issues with your vision, cramping, mood swings)? Explain.
Are you currently having any High-Risk factors with this pregnancy? (i.e. Hyperemesis Gravidarum, Gestational Diabetes, Pregnancy Induced hypertension (PIH), Preeclampsia, Eclampsia, Placenta previa, Shorten cervix/ cerclage placement, Anemia, PCOS, Endometriosis)? Explain in detail.
Your Birth

We will have an additional form later for more details
Briefly explain how you would like your birth to go. Example: Natural, Doesn't matter, Free Birth, Labor at home, etc...idk is also ok.
Do you have a Birth Plan?
Would you like us to create a Birth Plan together?
Briefly explain how you would like your BIRTH to go. Example: Labor at home, No Epidural, Free Birth, Etc.
Do you have any fears regarding pregnancy or childbirth?
YesNo
How do you cope with pain? Are you aware of different coping mechanisms/pain? (i..e. hypnobirthing, meditation, deep breathing exercises, yoga, positioning, hot/cold therapy)
Use this space to state anything medically wise that you would like to enclose. Think about your partners history and family history during this time.
Post Partum Plan

Below involves postpartum. There will be an additional Birth Plan form sent out at a later time.
Do you plan to breast or formula feed or both? It is important to pick an option.
Have you studied upon breastfeeding and its techniques?
Do you have a postpartum plan? Describe what it looks like.
MomDadSpousePartnerDoulaMidwifeFriendsOther
What is the ideal birth environment that you envision? (i.e. aromatherapy, hydrotherapy, dim lighting, music therapy, minimal guest during active labor, in hospital or out of hospital birth)
Extras & Add Ons

All optional
YesNo
Baby Bundle: 3 Onesies, Blanket, Keepsake, Custom Bag & Secret gift for mom ($75)Mommy Bundle: Shirt, Gown, Eye Mask, Wine Glass or Mug, Tumbler & Journal ($100)Family Bundle: Mom & Dad Shirts, Mom & Dad Robes, Mom & Dad Drinkware & Secret Gift ($150)Sibling Promotion Set: Shirts for sibling(s), Socks, Cup & backpack ($50)
If you haven't already, please select a date and time you would like to have our consult. Keep in mind, if the date or time doesn't work, I will contact you to set up an appointment. If you have already booked a date and time, please ignore :)
After our appointment, I will send over an invoice of your payment preference. 25% is due to book while the remainder is split into payments of your choice or the regular biweekly setting. You are also able to opt into “Pay in Full”. State how you would like to make your payment. *
Diamond Burrell

Certified Doula

Blood Pathogens Certfied

Basic Life Support Certified
Signature*
Should be Empty:

D. Unique Doula Intake Form

Basic Information

Lets Get Personal

Medical Intake

Your Birth

Post Partum Plan

Extras & Add Ons