New Client Intake Form

New Client Intake Form

Thank you for taking the time to answer these questions. This questionnaire is to help me get to know you better and how to best serve you! Everything you share with me is 100% confidential and I will never share any of your information or our talks, visits, photographs, or birth info without your Express permission. Your body, baby, and pregnancy are strictly your own and my job is to help you explore this experience, empower you, advocate for you, protect your sacred birthing space, and give ideas to achieve the birth you desire most. The questions in this document may not all apply to you so just answer the ones that do. You are always entitled to change your mind, and this is not a binding contract by any means. You do not need to feel obligated to share anything with me that you are not comfortable doing. I promise first and foremost to always respect you and your family, and you have the right to change your mind at any time no questions asked. Along your journey the answers may change, and I will be keeping in touch with you to stay up to date and help you along should you choose to hire me.
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Partner's Name (if applicable)

First NameLast Name
Partner's Phone Number

Area CodePhone Number
Partner's Email
example@example.com
Due Date or Baby's Birth Date*

MonthDayYear
Date
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Which services are you interested in?:

Birth SupportPostpartum SupportPlacenta EncapsulationLactation SessionsPartner GuidanceMeal PrepTrauma/Emotional Healing through guided meditationBirth Pool Rental
Support Information Sections

To ensure we gather all the necessary information, please click the arrow to the right of both "Birth Support" and "Postpartum Support" if you are considering services in either area. Answer the questions within each expanded section as completely as possible.

Postpartum Support Questionnaire- click the arrow to start ->
Postpartum Support

Fill out the section below if you are interested in postpartum support services. If not, then skip this section.
The Role of a Doula during postpartum support is to help with educational information surrounding life with a new baby, newborn care, postpartum recovery and offer professional guidance as well as physical and emotional support for the family. Please ask as many questions as possible to make sure the doula is the right fit for your family. Postpartum is a very important part of the birth process and it is important to have extra hands helping during the closing of one chapter and the beginning of a whole new one. The phrase “it takes a village” rings true with wisdom.
Are you looking for:

Daytime SupportOvernight SupportCombination of both
Approximately how long do you feel you will need support?
days, weeks or months.
What help are you wanting during postpartum visits/shifts.
Keep in mind that needs can change on a day-to-day basis, just give a general idea of what kind of help you are looking for your postpartum recovery.
Are you also looking for help with: (choose all that apply)

BreastfeedingbottlefeedingInformation on formulaInformation on Pumping