SS Doula Care Intake Form

SieloLuxe Wellness Service Intake Form
Thank you for your interest! Please fill out this form to help me understand your needs and how best to support you. This form is the first step and does not confirm services until we connect.

Please note: The information you provide in this form will be used for all aspects of your service, including shipping (if applicable), payment processing, scheduling, and appointment reminders. Please provide accurate and up-to-date details to ensure smooth communication and delivery.
Client's Name*

First NameLast Name
Client's Phone Number*
Example: (555) 555-5555
Partner's Name (optional)

First NameLast Name
Partner's Phone Number (Optional)
Example: (555) 555-5555
Your Home Address*

Street

House Number

CityState / Province

Postal / Zip Code
Client's Email*
example@example.com
Partner's Email (optional)
example@example.com
1. Service Interest

Please select the service(s) you’re interested in. If you're unsure, feel free to choose multiple.
Which service(s) are you interested in?*

Postpartum Doula SupportRoot, Release, Rejuvenate — 1 on 1 SessionKeepsake ServicesWellness Products/ToolsOther
Who is this service for?*
2. Service - Specific Questions

Please answer each question associated with the service(s) you’re interested in. Once you have filled out the questions for the service(s) you’re interested in, skip to section 3 Final Acknowledgments & Next Steps.
Postpartum Doula Support

A consultation is required for this service. Despite having this information, the call will serve as an ice breaker so we can begin to establish our relationship.
What state are you located in? (Include city if comfortable)
Is this your first child?

YesNoOther
What is your baby’s due date or date of birth? (if applicable)

MonthDayYear
Date
Ideal start date for postpartum support? (if applicable)
Do you have a partner, friend, or other support person at home?

YesNoSometimesOther
What length of support are you considering?

2 Weeks4 Weeks6 Weeks8 Weeks12 WeeksOther
What kind of postpartum support are you most interested in?

Baby care (feeding, diapering, bathing)Parent recovery & emotional supportSibling transitionRest & sleep guidanceLight meal prepHousehold help (light cleaning, tidying)Resource & referral supportAll The AboveOther
Will you need overnight support?

YesNoSometimesNot SureOther
Is there anything emotional, cultural, or spiritual you’d like honored during postpartum care?
Do you have any known challenges, mental health considerations, or boundaries you want me to be aware of?
Is there anything else you want me to know about your needs, family, or home environment?
Client Acknowledgment (Required):

I understand that this information helps provide informed intentional care to ensure your needs are being metI understand that pricing, contracts, addendums, and payment details will be provided only after confirming interest of this service.I understand this service requires a consultation to break the ice while better understanding the your needs and service expectations.I understand any additional knowledge will be addressed during our call and listed in the contract/agreement.I agree to respond in a timely manner to secure my spot.
Root, Release, Rejuvenate : 1 on 1 Session

A consultation is required for this service. This is your space to speak freely and let it out. No fixing. No shame. Just a safe, sacred space where every emotion is welcome and your truth is never too much.
What are you hoping to explore, process, or release during this session?
Is this your first time doing a session like this?

YesNoNot SureOther
What emotions or patterns have been coming up for you lately?

Anxiety or overwhelmGrief or sadnessGuilt or shameAnger or frustrationFeeling stuck or confusedDeep joy or expansionDisconnect from body/selfLoss (identity, relationships, pregnancy, etc.)Other
What do you most need from me during this session?

Quiet space to be heard (Vent)Gentle guidance or questionsReflection or mirroringSpiritual/emotional groundingNervous system calmingNo advice unless I ask for itEncouragementOther
How do you prefer to be supported when emotions arise?

Silence and presenceVerbal check-insOther
Are there any emotional boundaries or sensitivities I should honor?
Is there anything else you'd like to share before we meet?
Is there anything you do that helps you feel safe, regulated, or centered that you’d like to use during or after our session?
Payment Acknowledgment – This session is a Pay What You Want service. Payment is required before booking. Once payment is received, you will be sent a private link to schedule your session.

I understand that payment is required to secure my Root, Release, Rejuvenate sessionI understand I will receive a booking link only after my payment is confirmedI agree to respect the one-time session format and boundaries of this offering
Keepsake Service

Each keepsake has its own set of questions. Read thoroughly to ensure you selected the correct service. Confirm the acknowledgment portion of each service you choose.
Keepsake Boxes
What size Keepsake Box would you like to order?

Mini (8x8)Standard (10x12)Large (12x16)Extra Large (16x20)
What types of items do you plan to include in your box?
Example: pregnancy test, pictures, jewelry, etc.
Would you like to include a checklist of the items you send (to ensure nothing is missed)?

YesNoNot SureOther
List the items below (if applicable)
Would you like anything special added to the inside of the box?

A handwritten note or quote (you provide the wording)A name tag or label (e.g., baby’s name, birth date)Fabric lining or ribbon detailsThemed curation (based on occasion, color, emotion)Scented insert (lavender, chamomile, etc.)No customizations (just a neat, thoughtful box)Other
Do you know when you plan to ship your items?

YesNoOther
Would you like to request a rush order?

YesNoOther
If yes, select the option that applies. (Skip if it does not apply)

Yes — I need it within 2 weeks (+$25)Yes — I need it within 1 week (+$45)Yes — I need it within 3 business days (+$65)
How would you like to pay for your service?

Split (50% deposit now and the remaining balance before initial delivery)Full amount upfrontI have a question about payment and need to discuss it before proceeding
NOTE: Turnaround time begins only once your materials are received.
It is your responsibility to ensure your items are mailed in a timely manner.
If your package is delayed or incomplete, this may delay your keepsake. Even if you selected a rush option.
Shipping Responsibility Acknowledgment (Required)

I understand that the turnaround timeframe (standard or rush) begins after materials have been received in full.I accept responsibility for mailing all required materials on time.I understand that shipping instructions will be sent to me after full payment has been received.I understand that I am responsible for properly packing and shipping all items.I understand that if I choose a rush option, I am still responsible for shipping promptly so the timeline can be met.
Belly Cast Mold Decorating
How would you like your belly mold decorated?

PaintedBedazzledFabric-coveredFreestyle (artist’s choice)Unsure (I need help deciding)
Do you have any specific color themes, designs, or inspirations you'd like included?
Would you like to send reference photos or a mood board? If yes, link information below or email references.
Do you have any questions or concerns about your mold or decoration options?
Do you understand that you are responsible for safely shipping the completed mold to the studio?

I understand and agree
Is your belly cast fully dried, firm, and free of cracks or soft spots? (Helps avoid damaged shipments)

YesNo
Would you like to request a rush order?

Yes — I need it within 2 weeks (+$30)Yes — I need it within 1 week (+50)Yes — I need it within 3 business days (+$80)No — standard 2–6 week turnaround is fine
How would you like to pay for your service?

Split (50% deposit now and the remaining balance before initial delivery)Full amount upfrontI have a question about payment and need to discuss it before proceeding
Shipping Responsibility Acknowledgment (Required)

I understand that the turnaround timeframe (standard or rush) begins after materials have been received in full.I accept responsibility for mailing all required materials on time.I understand that shipping instructions will be sent to me after full payment has been received.I understand that I am responsible for properly packing and shipping all items.I understand that if I choose a rush option, I am still responsible for shipping promptly so the timeline can be met.
Keepsake Memory Quilt/Blanket
What size Keepsake Box would you like to order?

Small (36x36)Medium (40x54)Large (50x60)
What types of items will you be sending for the quilt?
Examples: Baby clothes, t-shirts, hospital blankets, onesies, burp cloths, etc.
Would you like to suggest anything for the quilt/blanket?
Examples: fabrics, patterns, shapes, filling, etc.
Would you like to request a rush order?

Yes — I need it within 2 weeks (+$75)Yes — I need it within 1 week (+100)No — standard 3–8 week turnaround is fine
How would you like to pay for your service?

Split (50% deposit now and the remaining balance before intial delivery)Full amount upfrontI have a question about payment and need to discuss it before proceeding
Shipping Responsibility Acknowledgment (Required)

I understand that the turnaround timeframe (3-8 weeks) begins after materials have been received in full.I accept responsibility for mailing all required materials on time.I understand that shipping instructions will be sent to me after full payment has been received.I understand that I am responsible for properly packing and shipping all items.I understand that if I choose a rush option, I am still responsible for shipping promptly so the timeline can be met.I understand that unused or extra materials will be returned.
Wellness Products and Tools

If you are interested in viewing the website beyond the information given in this section, a link will be provided via email.
Which wellness product(s) are you interested in?

Yoni SteamSmokable HerbsCrystalsSage, Smudges, IncenseHerbal TeasWaistbeadsSteaming KitsMen's Stem SteamingSelf Love KitsYoni Steaming Beginner KitsHerbal SupplementsLoose HerbsWholesaleOther
Do you have any known allergies or sensitivities I should be aware of before making product suggestions?
Acknowledgments (Required):

I understand that the products are purchased through a partnered third-party website, and that SieloLuxe Wellness LLC does not process or fulfill these orders.I acknowledge that all wellness product suggestions are non-medical in nature and provided for personal well-being.I understand that I am responsible for reviewing the product’s policies, ingredients, and usage instructions before purchase.
3. FINAL ACKNOWLEDGMENT & NEXT STEPS

Note: READ THIS SECTION THOROUGHLY BEFORE SIGNING AND SUBMITTING.
Thank you for taking the time to complete this intake form. The information you’ve shared allows me to:
- Personalize your service experience
- Prepare any necessary agreements or materials
- Determine whether a consultation is needed
- Ensure your emotional, physical, and logistical needs are honored
What Happens Next
- If your selected service requires a consultation, you will receive an email with booking instructions shortly.
- If your service does not require a consultation, I will follow up to confirm your request and send next steps.
Based on the service type, you will receive:
- A pricing summary
- Client contract, agreement and/or service addendum
- A secure payment link or invoice
- Shipping or scheduling instructions
- A confirmation of your session or product timeline
Client Acknowledgment (Required):*

I understand that this intake form helps SieloLuxe Wellness LLC provide informed, intentional care for each clientI understand that pricing, contracts, addendums, and payment details will be provided only after confirming interest in the serviceI understand that services requiring a consultation will be scheduled via emailI understand that services that do not require a consultation will move forward after communication and mutual agreementI agree to respond in a timely manner to secure my spot or product timeline
Free Consultation Request (Required):*

Yes — I would like a free consultation (mandatory for specific services)No — I’m ready to move forward without one
Should be Empty:

SieloLuxe Wellness Service Intake Form

1. Service Interest

2. Service - Specific Questions

Postpartum Doula Support

Root, Release, Rejuvenate : 1 on 1 Session

Keepsake Service

Wellness Products and Tools

3. FINAL ACKNOWLEDGMENT & NEXT STEPS