Birth with Tracey - Intake Form
Hello and thank you for your interest in working with me as your labor and birth doula. Please answer a few questions below:
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Your Information
Name *
First and Last
Pronouns
e.g. she/her; they/them
Your Date of Birth *
MM
/
DD
/
YYYY
Race/Ethnicity
This question is optional.
Phone Number *
Email Address *
Zip Code *
What is your household income? *
Everyone deserves support during their birth, regardless of income. The purpose of this question is to adjust service cost on a sliding scale.
Birth Information
Answer the questions below about your expected birth.
Expected Due Date *
MM
/
DD
/
YYYY
Planned place of birth *
Care provider type *
Is this your first birth? *
What doula package are you interested in? *
How did you hear about Birth with Tracey? *
How are you feeling about your upcoming birth? *
I don't feel good at all about my labor and delivery.
I feel great about my upcoming labor and delivery!
Anything else you want to share prior to our initial consultation? Any lingering questions or concerns that are top of mind?
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