Doula Intake Form

Sincerely Kyonne Birthing and Postpartum Services LLC.

New Client Intake Form
Congratulations on your pregnancy (or the birth of your baby)! 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/or postpartum!
Your Name*

First NameLast Name
Your Partner's Name

First NameLast Name
Doctor/ Midwife's / Practice name*

First NameLast Name
Hospital for Delivery*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Home Phone*

Area CodePhone Number
Cellphone

Area CodePhone Number
About your baby
Estimated Due Date/ Birth Date*

MonthDayYear
Baby's Gender

BoyGirlUnknown
Baby's name (if known)
Planned Method of Feeding

BreastfeedingFormula FeedingBothNot sure but would like more information
About your health
Please state your general health
Do you have any allergies I should be aware of?
Explain any complications you have had with this pregnancy, any restrictions your caregiver has given you, and any medications you are currently taking.*
Preparation for Birth/ Details of your Birth
Have you given birth before?*

NoYes,Vaginally onlyYes, Cesarean onlyYes,Vaginally and Cesarean
Have you taken or are you planning on taking any childbirth education classes? If so, what are they and where are you attending them?
Please list any other classes you have taken or plan on attending.
Who do you plan to have assist you with your labor? For Postpartum Clients: Who was there for your birth?*

PartnerDoulaMother/ Mother-in-LawSisterFriendOther
Who do you want present for the delivery?*
Do you have a birth vision planned?/ Did you have a birth plan?

Yes, It is a final copyYes, but it is a draft and would like some helpNo, I would like some help writing one.No, I have no interest in one.
How do you feel about interventions in labor/delivery? (birth clients only)
What type of pain management are you looking to have?

Comfort MeasuresIV MedicationEpiduralOther
What type of comfort measures would you like to use in labor?

DistractionsBreathing PatternsMassageBirth BallWalking, Dancing, SwayingWater (tub/Shower)Hot/Cold TherapyVisualization/ImageryFocal PointsAromatherapyMusic
What is your vision for this birth?
What are your expectations of me as your doula?*
Any other questions or concerns?
Should be Empty:

Sincerely Kyonne Birthing and Postpartum Services LLC.