Client Intake Form
I'm excited to be a part of this wonderful experience.  Please take a moment to complete this form so that I can better understand how I can support you in bringing your child into the world.
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You and Your Household
Name *
When is your birthday? *
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When is your expected due date? *
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Email *
Phone *
Street Address & Apt # (if any) *
City, State & Zip Code *
Do you have a partner? *
Required
Do you have a child or children? *
Required
How have you given birth before? *
Required
Did you use any interventions such as epidural, pitocin, forceps and vacuum extractors? *
Have you ever breastfed? *
Do you plan on breastfeeding? *
If any, list name(s) and age of people who live with you and their relationship to you.
Do you have a plan for who will take care of your child(ren) during your labor?
Clear selection
Do you have any pets?
Clear selection
If any, list the name(s) of your pet(s) and what type of pet.
Do you have a plan for who will take care of your pet(s) during your labor?
Your Health and Healthcare Provider
Have you chosen a doctor or a midwife? *
Required
Name of doctor or midwife *
Where will you give birth? *
Required
Name and Address of where you will give birth *
Do you have any preexisting health concerns?
How do you generally take care of yourself? *
Required
How have you taken care of yourself during pregnancy? *
Required
Your Birth Plan
How do you plan/would like to give birth? *
Required
On a scale of 1 to 5, how would you rate this statement? I do not want any medical interventions, including but not limited to epidurals, pitocin, the use of forceps and vacuum extractors. *
Who would you like to attend the birth?
How do you envision your birth? *
Do you have any specific requests/expectations of my role as your doula? *
Please use this space to share other important information such as fears, cultural/religious/personal preferences, and/or past experiences.  I am committed to supporting you regardless of your race, religion, class, gender/sexual identification and beliefs and will respect and honor your wishes and privacy.
How did you find me? *
Thank You!
I look forward to our first meeting.  I may have some follow up questions about your answers to this Client Intake Form.  In our next meeting, we will discuss how you envision your birth and create and/or discuss a Birth Plan, if you already have one.
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