New Client Intake Form

MA's Helping Hands Doula Services

New Client Intake Form
Congratulations on your pregnancy! Thank you for taking the time to fill out this form so we can get to know you better and have an idea of how we can best support you during your pregnancy, birth and/or postpartum period!

After submitting this form you will be taken to a page where you will schedule a Zoom session for us to meet "in-person".
Your Name

First NameLast Name
Your E-mail
Your Phone Number

Area CodePhone Number
Your Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Which services are you interested in receiving?
Estimated Due Date

MonthDayYear
Delivery Date

MonthDayYear
Doctor/ Midwife's / Practice name

First NameLast Name
Place of Delivery (only the locations listed are within our service area)
Your Partner's Name

First NameLast Name
Your Partner's Relationship to You
Your Partner's Email
example@example.com
Your Partner's Phone Number

Area CodePhone Number
How did you hear about MA's Helping Hands Doula Services? (check all that apply)

Other
How would you like to pay for your doula services
Who is your primary Insurance Provider? (we are currently accepting the Insurance companies listed)
How would you like to provide your Insurance information?
Please upload a picture of your Benefits Identification Card

Browse Files

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Insurance Member ID Number
Insurance Issue Date
Insurance Recipient's Birthdate
Are you a Kaiser Permanente Recipient?
How would you like to provide your Kaiser information?
Please upload a picture of your Kaiser Identification Card

Browse Files

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Kaiser Medical Record Number
Kaiser Recipient's Birthdate
Are you a TRICARE Prime or TRICARE Select Recipient?
How would you like to provide your TRICARE information?
Please upload a picture of your TRICARE Identification Card

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TRICARE Medical Record Number
TRICARE Recipient's Birthdate
About your baby
Baby's Gender
Baby's name (if known)
Planned/Current Method of Feeding
About your health
Please state your general health
Do you have any allergies I should be aware of?
Have you been placed in any of the following categories? (check all that apply)

Other
Explain any complications you have had with this pregnancy, any restrictions your caregiver has given you, and any medications you are currently taking.
Preparation for Birth
Have you given birth before?
Have you taken or are you planning on taking any childbirth education classes? If so, what are they and where are you attending them?
Please list any other classes you have taken or plan on attending.
Who do you plan to have assist you with your labor? (check all that apply)

Other
What is your vision for this birth?
Do you have a writen birth plan?
What type of pain management are you looking to have?

Other
What type of comfort measures would you like to use in labor?

Other
What are your expectations of me as your doula?
Any other questions or concerns?
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MA's Helping Hands Doula Services