• Client Intake Form

    A Dove's Love

  • Thank you so much for your interest in my services. Please fill out this form so I may know the best ways to offer you support. Congratulations on this new phase of your life.

     

  • Client Information

  • Format: (000) 000-0000.

  • PARTNER'S INFORMATION

  • Format: (000) 000-0000.

  • BIRTH PREFERENCES

  • Do you know the sex of your baby?*
  • Do you have a name for your baby?*
  • Do you have a primary attendant chosen for your birth?*
  • Where are you planning to give birth?*
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  • BIRTH Preferences

  • Do you plan to give birth:*
  • While most do not seek a C-section it is important to plan for this as a last resort. In the event of a C-section: Would you prefer a clear drape, which will allow you to see what is occurring?*
  • In the event of a C-section, would you prefer for your hands to be available, for example to hold your partner or a support person's hand or baby if applicable?*
  • In the event of a C-section, would you prefer for the care team (doctor and or nurse) to provide you with details on the step by step process of what they are doing?*
  • Current pregnancy history: Have you been diagnosed with any of the following?*

  • EDUCATION

  • PREVIOUS PREGNANCY INFORMATION

  • Have you given birth to multiples (twins, triplets, etc)?

  • HEALTH HISTORY

  • Do you use any of the following:*

  • ABOUT YOUR BIRTH: MOM

  • Do you have a birth plan/vision?*

  • ABOUT YOUR BIRTH: PARTNER

  • BIRTH EXPECTATIONS & RELEASE

  • Any fears or concerns related to this pregnancy or birth(physical/emotional)?*
  • What type of comfort measures do you think you would like to use during labor?*
  • Are you planning to breastfeed your baby?*
  • How do you pay for prenatal care (for your medical provider/ hospital)?*

  • RELEASE: I, the undersigned, agree that the above information is true to the best of my knowledge. I realize that Ashari Allen may not provide a medical diagnosis, or treatment of any physical or mental ailments, or recommend discontinuance of medically prescribed treatments. I understand that as a doula Ashari Allen offers emotional, physical, and informational support. I give my permission to receive emotional, physical, and informational support from my doula, Ashari Allen.

  • Any and all information in this form as well as through my services will remain confidential. As a doula, I am a mandated reporter and have a duty to report suspected abuse and neglect.

     

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