Client Intake Form
Client Information
name/partner's name
*
Persons first and last name the care is for
pregnancy due date
*
-
Month
-
Day
Year
Date
address:
*
phone
*
Format: (000) 000-0000.
email
*
example@example.com
healthcare provider
*
planned place of birth
*
birth center, home, hospital, etc.
Prior Pregnancy and/or Birth Experiences (skip if non-applicable)
Total number of pregnancies, including this one
*
Any history of fetal or infant loss?
*
N/A if none
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Have you experienced any complications with pregnancy?
Number of previous vaginal deliveries
Number of cesarean births
How did each of your labors begin?
Did previous births happen before, on or after your due date?
Length of time for labor(s)?
Did you experience any complications during labor or birth?
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Prior Breastfeeding Experience
Have you breastfed?
Did you have a positive breastfeeding experience?
Preparation for Birth
What service are you interested in?
*
Please Select
Radiant Service
Embodied Service
Select Consultation Appointment Date
*
What childbirth class have you or will you attend?
Will you be breastfeeding?
Are you currently experiencing any specific health or other concerns that affect this pregnancy?
How do you see the role of your doula?
During labor and birth, emotions associated with prior sexual abuse can come to the surface. As your support, it may be helpful for me to be aware if this issue exists and what your triggers are or may be. As with all of your information, any information you share will be kept confidential.
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