Postpartum Doula Intake Form

Names

Client's Birth Date

Date

Due date

Date

Address

Email Address

example@example.com

Phone Number

Calls, texts or emails preferred?

Calls texts or emails preferred

example@example.com

Emergency Contact Name

Relationship

Alt. Phone Number

Baby's Name(s)

Baby's Birth date

Date

Intended Place of Birth

Dr/Midwife Name

Are you taking time off work?

Is your partner taking time off work?

If so, how long

Any known allergies in the family?

If Yes Please Specify

Do you, or your partner if you have one smoke in the home?

How do you plan to feed your baby? (Pumping, Bottlefeeding, Breastfeeding, etc.)

Do you have any other children?

If yes, please list their names and ages

Do you have any other medical conditions I should be aware of, including allergies to essential oils or

If yes please specify

Do you or your partner have a history of mental health concerns or illness?YESNO

If yes please specify optional

Are you currently taking any medications?

If Yes, please specify (optional)

Do you anticipate your baby to have any medical concerns?

If yes, please specify

Do you plan on claiming birth doula support on your benefits/insurance plan?

Will you be needing a receipt in order to be reimbursed for birth doula support by your insurance/benefits?

Is there anything else you need in order to claim postpartum doula support in any way? please specify

Are there any parenting techniques you plan to use or have questions about?

What are your primary goals in having a Postpartum Doula?

How did you hear about my services?

Do you have any fears about parenting or the postpartum period?

What time of day do you anticipate Postpartum Doula services will be the most needed?

What tasks do you anticipate you will like the most help during the postpartum period?

Anything you would like to add

Thank you for taking the time to fill out these forms!

Please check to indicate your understanding of the following

I give permission to my Doula to use photos of me and my baby in printed materials. Each photo will be subject to your approval, and your permission may be revoked at any time

I give permission for my Doula to use photos of me and my baby on her website or online social media. (Each photo will be subject to your approval, and your permission may be revoked at any time

I understand that photography and video are not my Doula's main focus in the postpartum space.

As your Doula, | commit to keeping your personal information private and will not under any circumstances share that information with anyone. I respect your family's privacy and right to announce the long-awaited arrival of your baby, and will not share any photo or video on any platform or with anyone in person until you have indicated that it is ok for me to do so.

This postpartum photography, video and media release form has been reviewed and agreed to by the following persons as

designated by their signatures below:

Date

Parent (s)

Doula

Clients Name

Partners name if they have one

Length of time services were provided

Baby's Date of Birth

Did your Doula do anything specific that you found helpful during your postpartum period

Thinking back on your experience with your Doula what would you have changed Is there anything you would have wanted moreless of

Is there anything you feel your Doula could improve in the services that they provided

Anything you would like to add

Thank you for taking the time to share your feedback with me! I am committed to reflecting on my client's experiences in order to improve my practice, build on my skills, and grow as a Doula.

New Client Intake

Questionnaire

Postpartum Doula Evaluation Form