Nichelle’s Doula Services
New Client Survey
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Email *
Mommy’s Name *
Dad’s name and phone number (if applicable) *
Babies name and sex *
Expected Due Date *
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Mommy’s DOB *
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Mommy’s Email Address *
Mommy’s Phone Number *
Mommy’s Address *
Emergency Contact Name *
Emergency Contact Phone Number *
Name, phone number and address of mommy’s care provider *
How did you hear about Nichelle’s Doula Services? *
Tell me a bit about your pregnancy and baby. *
Is this your first pregnancy? *
Tell me about your previous births (if any). In what ways do you want this birth to be different or similar? *
What does your dream birth look like? *
What kind of birth related movies, books, blogs or classes have you been enjoying? *
What kind are you interested in? *
Have you taken or are you planning to take a child birth education class? *
How do you want to feel during your birth experience? *
How do you NOT want to feel during your birth experience? *
What do you expect from me as your doula? *
Would you like to receive a FREE 15 minute consultation? If so, please be prepared with at least 3-5 questions. *
Do you have a birth plan? *
What fears, worries or challenges are you experiencing right now, in regards to your pregnancy, labor, birth or postpartum? *
Are you in need of a payment plan? *
Are you in need of donated baby items? *
Are you in need of Pro Bono Services? *
Are you interested in virtual only services? This option is best for out of state mommy’s. Virtual Only services are $200! *
Please fill in the blank. “I want to look back at my birthing experience and say that is was _____.” *
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