Intake Form - Birth Doula Client
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Name *
Email *
Address *
Phone number *
Age *
Estimated due date *
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Who is your medical provider? *
Where are they located? *
Where do you plan to deliver? *
Name & address of delivery location *
What is your budget for doula services? *
How did you find me?
Have you or will you be taking a childbirth education class? If so, with whom? *
Do you have any special needs during your pregnancy and/or birth? If so, what are they? *
What is your current activity level? What exercises do you like best? *
Are you interested in learning more about prenatal fitness programming from me? *
Do you have any health issues that may or may not complicate your pregnancy/birth? If so, please explain. *
Why do you want a birth doula? *
How do you picture a birth doula serving you during pregnancy and birth? *
If this is not your first birth, please describe your prior births with as much detail as you can. *
Have you had any periods of mental illness, depression, anxiety disorder or postpartum depression  that you care to share with me?
Please describe your relationship with your parents.
Please describe what your ideal birth would be. Use as much detail as you'd like! *
What are your thoughts on intensity during labor? How do you see yourself coping during challenging moments in labor and delivery?
What are your specific desires for your upcoming birth? Do you have a birth plan? *
Do you have any cultural, religious or spiritual needs that you would like to share with me?
What are the three most important outcomes that you desire for this birth? *
Do you have any fears about this birth that you want to share with me?
Who else will be with you at your birth and what role will they play?
What type of comfort measures do you think you would like to use during labor? *
Required
How are you planning to feed your baby?
Are there any particular topics that you would specifically like to focus on during prenatal visits?
Comments/questions about ANYTHING?
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