Birth, Postpartum/Sleep Support Consultation Form
Jessica Argenzio CD/CPD(DONA), GSC RoseMoonBirthServicesLLC.com
Congratulations!
Thank you for considering me to walk through such an intimate time in your family's life! I cannot wait to connect and potentially start our bond as Doula/Gentle Sleep Coach & mama/mama to be. A great first step is to ensure that we are the right fit for one another. By taking some time to fill out this intake form, this will help if and how I can best assist you during pregnacy, birth, and postpartum. Thank you so much in advance and I very much so look forward to getting to know you! Please fill out the information below as best as you can, and once you finish you will be prompted to schedule a consultation/discovery call.
Your Full Name
First Name
Last Name
Your Date of birth
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Month
-
Day
Year
Date
Your Email
example@example.com
Your Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Your Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Birth Partners Name:
First Name
Last Name
Your Birth Partners Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Your Birth Partners Email:
example@example.com
Any Allergies in the Household?
How did you find us?
Google
Your website
I was referred by another independent Birthworker, Doula, or other Professional
Instagram
I was referred by a family/friend of mine (please specify below)
Richmond Birth & Baby
The Carrot Fertility Directory
Facebook
Other (please specify below)
If you were referred by a family/friend of yours, a previous client of mine or a perinatal/postpartum professional, please provide their full name below. Eligible referrals qualify for a $100 referral reimbursement via Venmo, or Zelle.
What Services are you interested in?
Birth Doula Support - $2000 (In-Person)
Overnight Postpartum/ Gentle Sleep Coaching Hybrid Support - $40-$50 per Hour
Virtual Only Doula Support - $850
Mentorship - I'm a newer doula looking for guidance (Put N/A for all questions)
Not exactly sure - I'd like more information on both (Birth & PP)
Both Birth & Overnight PP Sleep Support ($400 discount included in bulk purchase of birth & PP support of at least 9 shifts.)
Do you plan on paying out-of-pocket or do you have any employer benefits you'd like to use? (i.e. Carrot, Maven Clinic, etc.)
About you and your Pregnancy
Estimated Due Date
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Month
-
Day
Year
Date
Doctor/Midwife/Practice Name:
Desired Delivery Location (1st option)
Desired Delivery Location (2nd option)
Who is your Insurance/Fertility Benefit with?
Planned Method of Feeding
Exclusively Breastfeeding
Exclusively Formula
Combination
Not Sure - I would like to discuss it more
Are you experiencing any specific health concerns that may affect this pregnancy? (All information received and discussed is 100% confidential)
Please explain any complications you have had with this pregnancy or any restrictions your caregiver has give you.
Have you ever birthed a baby before?
No, this would be my first
Yes, Vaginally Only
Yes, Cesarean Only
Yes, Cesarean and Vaginally
Any history of miscarriage or infant loss?
No
Yes
How many living children do you have?
Have you or do you plan to take any childbirth education classes?
Have you planned for your postpartum at all?
If looking for overnight support, do you know how many nights per week of support you are looking for? Do you know how many weeks of support you are looking for? (I.e. 3-4 nights a week for 6-8 weeks) *Most Gentle Sleep Coach overnight support contracts are recommended to be at least between 3-7 shifts per week for 6-8 weeks long to assure long term benefit.*
What is your biggest concern for postpartum recovery?
How do the sleeping arrangements look for you and your baby during recovery? (ex: bed sharing, bassinet, room sharing, co-sleeping)
*Put N/A if inquiring for Postpartum Services* In 5 words, please describe how you would like to FEEL and how you would like your birthing environment to feel like? (ex: calm, peaceful, energized, exciting)
What is your vision for this birth? (put N/A for postpartum inquiry)
Are you a trauma survivor? If yes, do you have any triggers I should be made aware of and are you comfortable discussing them?
Anything else that I should know to better support you?
What is your faith/religion if any?
I’m a doula who holds my personal faith values close, but I never impose them on others. I fully support every woman’s right to complete bodily autonomy. Is that something you feel comfortable with?
Submit
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