Pregnancy Release/Abortion Doula Support Intake Form (Post-Abortion Doula)

Doula For The People Pregnancy Release/Abortion Doula Support Intake Form
Liberation Is a Lifestyle- We offer non-biased, physical, emotional, and trauma-informed care after a pregnancy release/ abortion-related experience- this includes miscarriage/pregnancy loss, medication at home, and procedures in clinic/hospital. Below is a more detailed outline of the support that we provide.

At Doula For The People, your privacy and safety are our top priority. We understand that seeking Pregnancy release/miscarriage/abortion support can be a deeply personal experience, and we are committed to maintaining the confidentiality of any information you share with us. All personal information shared in this intake form is kept secure and is only accessed by our trained team members who are directly supporting your care.We do not share your information with anyone outside of our organization without your explicit consent. To ensure that all communications remain private and protected, we use Signal, a free, encrypted messaging app. After submitting this intake form, you will receive an email or text invitation from our team with instructions to download Signal.
General Information
Full name of the person requesting services*

First NameLast Name
What are your pronouns (He/Him, She/Her, They Them)?*
Email Address*
example@example.com
When Are you hoping to receive doula support?

MonthDayYear
Date
Are you a minor?*

YesNo
If you are a minor, would you like us to use language that protects your privacy by encrypting the details of the services that you will be receiving? (if you answer "Yes" to this question, we will refer to ourselves as DFTP vs Doula For The People in all correspondence, and we will neutralize all other language used to reference our services)

YesNoNA
How were you connected to these services?*

Doula For The PeopleUCSF Mt.Zion Womens ClinicSan Francisco General HospitalBlack Women Birthing JusticeBlack Girls Mental Health FoundationSister WedCoco DoulasInstagramCommunity flyer
Are you Interested in in-person or virtual doula support? (virtual doula support comes with 6hrs of virtual support and a non-perishable care package. If you are out of state, or outside of our service area please select virtual services)

In-personVirtual
What type of pregnancy release/ abortion doula support are you most interested in receiving?

Pre-pregnancy release processing session (up to 2 hours)Meditation and groundingLight womb massageClosing of the bones ceremonyMeal PrepProcessing of your story- and ear to listen and hold spaceGrief supportHerbal support- Herbal teas or baths, steams tincturesSupport implementing mindfulness practices (affirmations, journal prompts)Education around fertility awareness method (FAM) & Cycle tracking as a form of contraception
Client phone number*
Please enter a valid phone number.
Physical Address*
How do you racially identify?
Do you have any food allergies?*
Doula Matching Questions
Why is having a doula important to you?
What qualities are most important to you in a doula?

KindDirectEmpatheticSpiritualGentleWarmFunnyLaid backInformativeWiseMotherlyFirmInstructiveHands on
If your best friends could describe you with 3 words which 3 words would it be and why?
What type of support are you most interested in receiving from your doula (All of our doulas are experienced in offering every type of support listed. This question is to get a sense of what is highest on your list of priorities)

Physical support/pain managementSpiritual and emotional supportNutritional support/ meal prepEducational support
What doulas in our collective are you most interested in being matched with? Your preference will be taken into consideration, but it's not guaranteed because of the nature of doula work. (link to doula headshots and bios https://doulaforthepeople.org/dftp-collective)

Alaina LeeBashari GeorgeBriana WellsBrianna TrejucoBriana Kikamoto FujiChay TadeoDesola AmosJoanna TurnerJaontra HendersonKyrsha PryorTiffany WashingtomTeyler WallaceShivani NarangNo Preference
Doula For The People Terms of Service Agreement

This agreement is between appointed (Doula For The People Doulas) , and (Clients) for the purpose of providing post-abortion doula care.

Responsibilities and Limitations of the Doula

The appointed Doula For The People (DFTP) doula's agree to provide non-medical physical, emotional and educational support, in the event of an abortion or a miscarriage.

DFTP doulas do NOT diagnose any medical conditions but can offer an evidance based opinion, and refer you to the appropriate health care provider if specialized care is needed.

Doulas will disclose any potential scheduling conflicts that may interfere with service. If your doulas are ever unable to provide support due to unforseen circumstances such as illness, injury, or family emergancy, they agree to reschedule services, or provide the availability of a back-up Doula.

Privacy & Communication Protocol

At Doula For The People, your privacy and safety are our top priority. We understand that seeking Pregnancy release/miscarriage/abortion support can be a deeply personal experience, and we are committed to maintaining the confidentiality of any information you share with us.

How We Protect Your Privacy

All personal information shared in this intake form is kept secure and is only accessed by our trained team members who are directly supporting your care.
We do not share your information with anyone outside of our organization without your explicit consent.

Secure Communication Requirement
To ensure that all communications remain private and protected, we use Signal, a free, encrypted messaging app. After submitting this intake form, you will receive an email or text invitation from our team with instructions to download Signal.

Why We Use Signal:

Signal uses end-to-end encryption, which means no one outside of our conversation — not even Signal — can read our messages.
It allows us to safely discuss your care and coordinate support while protecting your confidentiality.
Your Responsibility:
By completing this intake form, you agree to download Signal and use it as our primary communication channel for scheduling, support, and follow-up. If you have any concerns about using Signal, please let us know so we can work together to find a solution that prioritizes your privacy.

Our goal is to create a safe and secure space for you to receive the care and support you need.

Health & Safety/Covid Protocol

All parties acknowledge the ongoing COVID-19 crisis in the United States and accept their obligation to comply with any official guidance to mitegate the spread of the virus from the US Government. The parties agree to communicate without delay at the onset of any illness or covid exposure, so that any adjustment to the agreed upon schedule can be made.

In the case that either party has contracted COVID-19 or any other contagious illness, support will be rescheduled according to adherence of the most current CDC guidelines.

Details of Service

Upon signing of this contract, you are stating that you understand the responsibilities and limitations of your pregnancy release/ abortion doula, health and safety protocols and details of service.

- Up to 8 hrs of holistic pregnancy release doula support
- 12 Foodie Doula meals designed to support pregnancy release recovery
- A blood pressure cuff & thermometer to monitor recovery
- A wellness Journal to support emotional wellbeing

By completing this intake form you are agreeing to recieve pregnancy release/ abortion doula services via a DFTP doula. You are agreeing to take on the responsibiity of communicating with you doula about when and how you would like to recieve services, so that support can be administered in a way that honors your experience and needs.
Client Signature

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Doula For The People Pregnancy Release/Abortion Doula Support Intake Form

General Information

Doula Matching Questions