DoulaWill intake form

Full Spectrum Doula

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 and birth!

As your doula, my role is to walk alongside you - before, during, and after birth - offering presence, advocacy, and care rooted in trust.

I draw on my professional training — including full-spectrum doula education, culturally responsive care, and evidence-based practices — to support your mind, body, and spirit during pregnancy, labor, and birth. My approach blends emotional reassurance, physical comfort, and informed guidance, ensuring you have the knowledge and confidence to make decisions that feel right for you.

During labor, I can offer perspective and encouragement, suggest positions or comfort measures for progress, and use techniques such as massage, breathwork, relaxation, and movement to ease intensity. I also serve as a bridge between you, your partner, and your care team — helping you communicate your preferences clearly and understand the options presented to you in the moment.

My care doesn’t end once your baby arrives. In the postpartum period, I offer practical help and compassionate guidance so you can rest, recover, and bond with your baby. This may include newborn care tips, feeding support, emotional check-ins, light household help, meal preparation, sibling adjustment, and connecting you with trusted resources. Whether your needs are physical, emotional, or both, I provide a safe, steady presence so you feel less overwhelmed and more confident in your new role.

My work is independent and client-centered. I am not employed by your caregiver, birth center, or hospital. I work for you, always respecting your choices, your pace, and your vision for birth and postpartum recovery. My goal is for you to look back on your experience feeling empowered, cared for, and supported in body, mind, and spirit.
Client information
Full name*

First NameLast Name
Date of birth*

MonthDayYear
Age
Phone Number*

Area CodePhone Number
E-mail*
Preferred language*

EnglishHaitian CreoleSpanish
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How Did You Hear About DoulaWill?*
If referral or event/workshop, list name of person or event/workshop*
Services You’re Interested In (Check all that apply)*

Birth doula supportPostpartum doula supportPregnancy Release Support*Childbirth educationLactation supportBlessingway ceremonyVirtual doula supportPelvic floor and core wellness guidancePlacenta encapsulationOther
*Pregnancy release support is offered in accordance with applicable state laws (including Florida’s 6-week limitation) and local regulations in other locations.
Pregnancy details
Estimated due date*

MonthDayYear
How many weeks are you today?*
Is this your 1st pregnancy?*
How many babies?*

SingleTwinsTripletsMoreI do not know yet
Number of prior births*
Number of prior miscarriages/terminations/stillbirths*
Baby's Gender*

BoyGirlUnknown
Planned Place of Birth*

HospitalBirth CenterHomeUndecided
Name of place of hospital/birth center (if applicable)*
OB/GYN or Midwife name*
Your general health
Do you have any past or current pregnancy complications?*
If yes, please explain*
Do you have any current diagnosis I should be aware of?*
If yes, please explain (e.g., hypertension, diabetes, anemia, hepatitis B or C, etc)*
Are you currently on any medications? If yes, list below*
Do you have any allergies I should be aware of? If yes, list below*
Mental Health History (e.g., anxiety, depression, PTSD)*
Any prior birth trauma or difficult reproductive experiences?*
Do you need HIV related pregnancy support?*
Health insurance
Do you have health insurance?*
If yes, Insurance Company Name*
Plan Name/Type (e.g., Medicaid, PPO, HMO, EPO)*
Policy/Member ID Number*
Group Number (if applicable)
Plan effective date (coverage start date)
Plan expiration date (if applicable)
Subscriber name
Subscriber date of birth
Subscriber relationship to client
Subscriber Employer name (if employer based)
Upload/Copy of Insurance Card

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Postpartum planning
Have you given birth before?*

NoYes,Vaginally onlyYes, Cesarean onlyYes,Vaginally and Cesarean
Planned Mode of Birth:*

VaginalC-sectionVBACUndecided
Have you taken any childbirth classes before? *
If yes, which class?*
Please list any other classes you have taken or plan on attending.*
Planned Method of Feeding*

BreastfeedingFormula FeedingBothNot sure but would like more information
Who do you plan to have assist you with your labor?*

PartnerDoulaMother/ Mother-in-LawSisterFriendOther
Any specific birth preferences, cultural traditions, or rituals you’d like honored?*
Do you have a birth vision planned?*

Yes, It is a final copyYes, but it is a draft and would like some helpNo, I would like some help writing one.No, I have no interest in one.
How do you feel about interventions in labor/delivery?*
What type of pain management are you looking to have? *

Comfort MeasuresIV MedicationEpiduralOther
What type of comfort measures would you like to use in labor?*

DistractionsBreathing PatternsMassageBirth BallWalking, Dancing, SwayingWater (tub/Shower)Hot/Cold TherapyVisualization/ImageryFocal PointsAromatherapyMusic
What are your biggest hopes for your birth/postpartum experience?*
Excluding a healthy baby
What is your vision for this birth? *
What are your biggest fears or concerns?*
Do you have any cultural or religious rituals you'd like to present at your birth?*
What are your expectations of me as your doula?*
Are you a trauma survivor? If yes, are there any triggers I should be made aware of and are you comfortable with discussing them?*
Any other questions or concerns?*
Practical & Scheduling
Preferred appointment times*

MorningAfternoonEvening
Virtual or in person*

VirtualIn personBoth
Any transportation challenges?*
What is your budget?*
Thank you for completing your intake form. I appreciate you sharing your details with me. I’ll review everything and be in touch soon to set up our time to go over it together
Appointment
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Full Spectrum Doula

Client information

Pregnancy details

Your general health

Health insurance

Postpartum planning

Practical & Scheduling