Client Intake Form
Your Name
*
First Name
Last Name
Birth Partner's Name
First Name
Last Name
Doctor/Midwife/Practice Name
*
Hospital, Birthing Center, or Place of Delivery
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Your Baby
How many weeks pregnant are you?
Estimated Due Date
*
-
Month
-
Day
Year
Date
Baby's Name (if known)
Planned Method of Feeding
Breastfeeding
Formula Feeding
Both
Not sure, but would like more information
Your Health
Medical History
Any allergies?
Any current complications, restrictions, or medications?
Any history of Mental Illness?
Birth Preparation
Have you ever given birth before?
*
No
Yes, Vaginally only
Yes, Cesarean only
Yes, Vaginally and Cesarean
What is your birth plan for this pregnancy?
*
Undecided
Vaginally
Cesarean
Have you taken or do you plan on taking any Childbirth Education classes? If so, which classes and where?
Please list any class you have taken or plan on taking.
Who do you plan to have assist you in labor? (check all that apply)
*
Partner
Doula
Parent/InLaw
Sibling
Friend
Other
Who do you want present for the delivery?
*
Do you have a birth vision planned?
*
Yes, it is finalized
Yes, but would like some help with it
No, but would like some help creating one
No, not interested in one
How do you feel about interventions in labor/delivery?
What type of pain management are you looking to have?
*
Non-medicinal comfort measures
IV Medication
Epidural
Other
What type of comfort measures would you like to use in labor?
Distractions
Breathing patterns
Massage
Birth Ball
Walking, Dancing, Swaying
Water (tub/shower)
Visualization/Imagery
Rebozo
Aromatherapy
Music
Other
What is your vision for this birth?
*
What is your plan for your placenta?
Placenta Encapsulation
Lotus Birth
Delayed Cord Clamping
Cord Blood Bank
None of the above
Not sure, but would like more information
Other
What are your expectations of me as your Doula?
*
Are you looking for postpartum support?
Yes, please discuss my options with me
Not interested
Not sure, would like more information
Other
Any other questions or concerns?
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