I am so honored to be able to support you as your doula! Before we meet for our first prenatal, please complete this intake form to help be get a better sense of the kind of birth experience you want and how I can best support you as your doula.  We will then go over your responses together. 

 

Pregnant Person Full Name *
Pregnant Person Full Name
Pregnant Person Date of Birth *
Pregnant Person Date of Birth
Birth Information
I.e. Home, Hospital, Birthing Center
Have you toured the birthing location?
Have you taken a prenatal class?
Contact Information
Your home address.
Address *
Address
Phone #1 *
Phone #1
Partner/Support Person Phone
Partner/Support Person Phone
Medical History
Medical conditions pertinent to labor and childbirth
Childbirth Education
If you’ve already taken a childbirth ed class, please note any topics you want to discuss further:
Labor and Birth Preferences
Who would you like to be present during your labor?
Do you want any of the following non-medical choices during labor?
Do you want any of the following medical choices for Early Labor?
Do you want any of the following to occur for the birth?
If your HCP suggest that you have an induction/Augmentation, do you want any of the follow?
If you have a scheduled Cesarean Section or your HCP states that you need one, do you want?
Do you have any special choices?
Newborn Care & Feeding
Postpartum Period
Do you want the HCP/staff to:
Do you want?
Baby's Sex
Additional Resources
Do you want any additional information on the following:
Ever so often I like to update my website and other printed materials. If you would be willing to allow me to use your photographs, with your name (if desired) taken of your birth (non-explicit photos only), please let me know.