New Client Intake Form
Basic Information
Parent 1 Name
First Name
Last Name
Parent 2 Name
First Name
Last Name
Address (where support service would occur)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent 1 Phone Number
Format: (000) 000-0000.
Parent 1 E-mail
example@example.com
Parent 2 Phone Number
Format: (000) 000-0000.
Parent 2 E-mail
example@example.com
Emergency Contact #1
First Name
Last Name
Emergency Contact #1 Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact #2
First Name
Last Name
Emergency Contact #2 Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Home Information
Parent 1 Occupation
Parent 2 Occupation
Will the birthing parent be taking time off work?
Yes
No
Undecided
If yes, how much time?
Will the second parent be taking time off work?
Yes
No
Undecided
If yes, how much time?
Are there other children in the home? Please list names and ages.
Are there any known allergies in the family? Please specify.
Are there pets in the home? Please specify.
Does anyone smoke in the home?
Yes
No
Are there any firearms in the home?
Yes
No
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Baby Information
Due Date
-
Month
-
Day
Year
Date
Feeding Plan
Breastfeed
Bottle Feed
Both
Undecided
Midwife/OBGYN Name
Where do you plan to deliver the baby?
Does the baby have any known medical conditions? Please specify.
Are there particular parenting techniques you plan to use or have questions about?
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Family Information
What birth/baby preparation (if any) have you done? Classes taken, books read, etc.
Are there any pregnancy complications or pre-existing health issues for the birthing parent? Please specify.
Is there a history of depression, anxiety, or other mental health issues with either parent? Please specify.
Does the supporting parent have any medical issues the doula should be aware of? Please specify.
What particular concerns about birth, postpartum, or parenting do you have that you would like support with?
What are your main reasons for hiring a postpartum doula?
Emotional Support
Birthing Parent Physical Recovery Care
Infant Care Guidance
Breastfeeding Help
Household Maintenance
Sibling Adjustment
What are your primary goals for using postpartum doula support?
How much total support time do you anticipate needing?
Less than 6 hours
6-12 hours
12-18 hours
More than 18 hours
Unsure
What span of time would you like support for? (Check all that apply)
Weeks 1-4
Weeks 4-8
Weeks 8-12
Unsure
What times of day would you like support? (Check all that apply)
Morning (8am-12pm)
Afternoon (12pm-4pm)
Evening (4pm-8pm)
Is there anything else you'd like the doula to know?
Nurturing New Families offers prenatal education classes. Please check any that you're interested in taking before your baby arrives.
Empowered Birth
Preparing for Postpartum
Breastfeeding Basics
Newborn Care
How did you hear about Nurturing New Families?
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