Request edit access
Birth Intake Form
Fill out to the best of your ability. Do not be intimidated if you cannot or do not know how to answer a question, those are things we'll work through together!
Sign in to Google to save your progress. Learn more
Email *
Name & age *
Emergency Contact name, email, phone number
If you have a partner, please share their name, email, phone number.
If same as the above, you can skip! 
Due Date/Range *
MM
/
DD
/
YYYY
Who is your physician? Please provide their name, their group (if applicable), and contact information.
Where do you plan on giving birth?
Home, hospital (please provide name of hospital), birth center (please provide name of birth center)
Who else do you plan on being present at the birth and what role do you want them to play? *
include everyone!
Which types of birth have you experienced?
Please check all that apply.
Please list any and all complications you had in your previous pregnancy(ies):
For example: Gestational diabetes severe insomnia, anxiety, depression, severe morning sickness, anemia, headaches, pica, back injury/pain, preeclampsia, diastasis recti, etc. Anything you'd want me to know that was not ideal from your previous pregnancy.
Have you had any restrictions during this pregnancy directed from your caregiver? Any special needs?
What are you hoping to learn about before your birth? *
Check all the apply! 
Required
What comfort measures would you like to use in labor?
Do you have any religious or cultural beliefs that you would like me to be aware of?
What are your expectations of me as a doula?
Have much does your partner know about pregnancy, labor and birth versus how much you would like them to know?
On a scale of 1-10, how much does your partner (or person present at birth) know about pregnancy, labor, and birth?
Birth new-bie
Birth expert
Clear selection
On a scale of 1-10 how much do you want your partner to know about pregnancy, labor, and birth?
NOTHING!
EVERYTHING!
Clear selection
Do you have any persistent fears regarding your birth?
What have you found to be comforting in previously intense moments of your life?
What do you think you will call on as your greatest strength for your pregnancy/birth/postpartum experience?
Where do you think your greatest challenge or hurdle will lie?
Are you interested in postpartum support?
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms