Doula Intake Form

Empowered Pregnancy Doula Services

Perspective Client Intake Form
Congratulations on your pregnancy! 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 postpartum!

Once your form is received I will reach out to schedule your Free virtual consultation. (please allow 24-48 hours for a response)

Thank you!

Doula LaTanya (Tammy) Fulton

* Indicates required question
E-mail
example@example.com
Your Name*

First NameLast Name
Date of Birth**

MonthDayYear
Date
City, State & Zip *
Cellphone
Hospital/Birthing Center for Delivery*
Due Date*

MonthDayYear
Date
How did you hear about Empowered Pregnancy Doula Services

ReferralSocial MediaHealthcare ProviderThe Doula NetworkOther
Is this your first pregnancy

YesNo
If this is not your first pregnancy, have you ever had a C-section?

YesNo
Planned Method of Feeding

BreastfeedingFormula FeedingBothNot sure but would like more information
If you've had a C-section, what was the reason and how long ago"
This is a*

SingletonTwinTriplet Pregnancy
Do you have a history of preterm labor

yesNo
Do you have a history of miscarriage or stillbirth?*

YesNo
Are you experiencing any prenatal complications in this pregnancy?*

Group B StrepPreeclampsiaGestational DiabetesMultiples PregnancyIUGR (intrauterine growth restriction) aka "low birth weight"Other
What type of healthcare provider are you working with"*

MidwifeOB (obstetrician)GP (general practitioner)
Name of Healthcare Provider*
Do you have any other medical conditions I should be aware of?, including allergies to essential oils or honey?*
Do you have s specific religion or cultural belief that you practice and would like me to be aware of? If YES, please provide below.*
Do you plan on taking any classes to help prepare for birth (i.e.: childbirth, breastfeeding, newborn care, Infant CPR, etc)?*

YesNoUndecided
If yes, please list additional classes you are taking/plan to take.*
Are you taking any prescription medications or supplements (i.e.: prenatal vitamin, iron, etc.)*

YesNoOther
Do you have any fears or concerns around birth? (i.e..: medical interventions, pain management, breastfeeding, newborn care, breastfeeding, postpartum care, etc.)?*
Please note any special interest topics of interest that you would like to learn more about:*

Nutrition & WellnessLabor Preparation (Comfort Measures, Pain Medication, Labor Positions, etc.)Advocating for YourselfPostpartum Care)Newborn CareInfant Feeding (Breastmilk/Formula)Other
Please list any other thoughts that you feel would assist me in learning more abut your pregnancy.
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Empowered Pregnancy Doula Services

Thank you!

Doula LaTanya (Tammy) Fulton