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

  • Date of Birth**
     - -
  • Format: (000) 000-0000.
  • Due Date*
     - -
  • How did you hear about Empowered Pregnancy Doula Services
  • Is this your first pregnancy
  • If this is not your first pregnancy, have you ever had a C-section?
  • Planned Method of Feeding
  • This is a*
  • Do you have a history of preterm labor
  • Do you have a history of miscarriage or stillbirth?*
  • Are you experiencing any prenatal complications in this pregnancy?*
  • What type of healthcare provider are you working with"*
  • Do you plan on taking any classes to help prepare for birth (i.e.: childbirth, breastfeeding, newborn care, Infant CPR, etc)?*
  • Are you taking any prescription medications or supplements (i.e.: prenatal vitamin, iron, etc.)*
  • Please note any special interest topics of interest that you would like to learn more about:*
  • Should be Empty: