Client Intake Form

Client Intake Form

Please complete this form to refer a patient and provide consent to share information.
Client Information

Please provide the patient's details below.
Client Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient Email Address
example@example.com
Patient Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name and Number
Race

Other
Ethnicity

Other
Gender

Other
Marital Status

Other
Age
Education
Employment
Estimated Annual Household Income
Total Household Size
Primary Language
Pregnancy/Birth Details
Baby's estimated due date or date of birth
Number of babies
Birth Place
Name of Hospital/Birth Center
Delivering Provider
Method of Payment
Insurance Company Name
Member ID Number
High-risk or notable factors (Check all that apply):

Other
Referring Provider or Organization
Who is making the referral?

Other
Referring clinic/agency:
Referrer Full Name

First NameLast Name
Referrer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referrer Email Address
example@example.com
Has the patient agreed to this referral?
Do you want follow‑up about referral status?
Reason for Referral (Check all that apply):

Other
Requested Service

Sereni Postnatal Retreat, Inc. will provide up to three (3) prenatal and postpartum home/virtual visits during the first 12 weeks after birth, plus resource navigation as needed.
Which services are you interested in? (Check all that apply):

Other
Have you worked with a doula before?
Is there anything the team should know to prepare for a safe, respectful visit (pets, safety issues, language needs, cultural/religious preferences)?
Patient Consent to Share Information

Please review and provide your consent below.
Patient Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Privacy Statement & HIPAA Notice
Your information will be kept confidential and handled in accordance with HIPAA and our organization's privacy policies. For more details, please contact our office by email at serenipostnatalretreatinc@gmail.com, or visit our website at www.birthingwithserenity.com.
Should be Empty:

Client Intake Form

Client Information

Pregnancy/Birth Details

Referring Provider or Organization

Requested Service

Patient Consent to Share Information