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
ReferralSocial MediaHealthcare ProviderThe Doula NetworkOther
YesNo
YesNo
BreastfeedingFormula FeedingBothNot sure but would like more information
If you've had a C-section, what was the reason and how long ago"
SingletonTwinTriplet Pregnancy
yesNo
YesNo
Group B StrepPreeclampsiaGestational DiabetesMultiples PregnancyIUGR (intrauterine growth restriction) aka "low birth weight"Other
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.*
YesNoUndecided
If yes, please list additional classes you are taking/plan to take.*
YesNoOther
Do you have any fears or concerns around birth? (i.e..: medical interventions, pain management, breastfeeding, newborn care, breastfeeding, postpartum care, etc.)?*
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