Doula Intake Form

Birth Doula Services

New 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!
Your Name

First NameLast Name
Your Partner's Name

First NameLast Name
Doctor/ Midwife's / Practice name

NamePhone Number
Location for Delivery
Please specify which hospital, birth center, or home birth
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Cell phone

Area CodePhone Number
Partner’s cell phone

Area CodePhone Number
About your baby
Estimated Due Date

MonthDayYear
Baby's Gender
Baby's name (if known)
Planned Method of Feeding
About your health
Your Birthdate
Please state your general health
Do you have any allergies I should be aware of?
Explain any complications you have had with this pregnancy, any restrictions your caregiver has given you, and any medications you are currently taking.
Preparation for Birth
Have you given birth before?
Have you taken or are you planning on taking any childbirth education classes? If so, what are they and where are you attending them?
Please list any other classes you have taken or plan on attending.
Who do you plan to have assist you with your labor?

Other
Who do you want present for the delivery?
Do you have a birth vision planned?
How do you feel about interventions in labor/delivery?
What type of pain management are you looking to have?

Other
What type of comfort measures would you like to use in labor?
What is your vision for this birth?
What are your expectations of me as your doula?
Any other questions or concerns?
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Birth Doula Services