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?*

Pregnancy, Labor & Delivery, and PostpartumPregancy and/or Labor & Delivery onlyPostpartum Only
Estimated Due Date*

MonthDayYear
Delivery Date*

MonthDayYear
Doctor/ Midwife's / Practice name*

First NameLast Name
Hospital of Delivery*
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
Who is your primary Insurance Provider?
Are you a Medi-Cal Recipient?*
How would you like to provide your Insurance information?*
Please upload a picture of your Benefits Identification Card*

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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*

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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

BoyGirlUnknown
Baby's name (if known)
Planned/Current Method of Feeding

BreastfeedingFormula FeedingBothNot sure but would like more information
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 high-risk categories? (check all that apply)

You are under 17 years of ageYou are over 35 years of ageYou are carrying multiple babiesYou have a history of preterm laborYou have a history of C-sectionYou have a history of pregnancy lossYou have delivered a child with a birth defectYou have a family history of genetic conditionsYou have a heart conditionYou have epilepsyYou have kidney diseaseYou have polycystic ovary syndrome (PCOS)You have problems with the structure of the uterus, cervix or placentaNone of the aboveOther
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?*

NoYes,Vaginally onlyYes, Cesarean onlyYes,Vaginally and Cesarean
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)*

PartnerDoulaMother/ Mother-in-LawSisterFriendOther
What is your vision for this birth? *
Do you have a writen birth plan?*

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.
What type of pain management are you looking to have? *

Comfort MeasuresIV MedicationEpiduralI'm not sureOther
What type of comfort measures would you like to use in labor?

DistractionsBreathing PatternsMassageBirth BallWalking, Dancing, SwayingWater (Tub/Shower)Hot/Cold TherapyVisualization/ImageryFocal PointsAromatherapyMusicPossitive AffirmationsI'm not sureOther
How did you hear about MA's Helping Hands Doula Services? (check all that apply)*

Web SearchOB/GYNLa ClinicaCCHPSolano Doula GroupPrevious ClientFacebook/InstagramYelpOther
What are your expectations of me as your doula?*
Any other questions or concerns?
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MA's Helping Hands Doula Services