Doula In-Take Form

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Doula In-Take Form

Greetings Mama,

This is my general intake form for our work together.

By filling out this form, you are welcoming me to get to you know better, and share insight on how I can best serve you as a doula. Please fill out all questions in your honest thoughts. If you have any questions, you are welcome to email me or reach out to me directly! This will help us during our free consolation to know your desires & needs for my service.

Full Name *

If applicable, what is your partner's name? *

Do you have any other children? What are their names and ages? *

If applicable, can you please share with me the experience of your past birth/births?

All the way from pregnancy, birth, & postpartum, at any time did you feel disrespected or unwell? -why *

All the way from pregnancy, birth, & postpartum, at any time did you feel disappointed or let-down? *

All the way from pregnancy, birth, & postpartum, at any time did you feel the experience of anxiety, fear, or depression? *

All the way from pregnancy, birth, & postpartum, at any time did you feel joyful, honored, & deeply nourished? -why *

Please share with me how you found my work? This helps me refine my marketing efforts! *

What is your home mailing address? Also, is this your residential address? *

When is your estimated due date? *

YYYY

Where are you planning to do your birth? *

What is your main care provider's name & contact information? *

Do you have any known illnesses, diseases, infections, or similar that I should know about? This information is integral in the ways I can react to emergency scenarios and/or prevent contamination or contagion. *

Do you and/or your partner and/or your children have any dietary requirements, allergies, or intolerances? This information is integral in the ways I prepare, deliver, and bring food & beverage into your space. *

Do you currently take any supplements, vitamins, and/or medications? *

Please outline foods & drinks that both you (and/or partner) enjoy the most. *

What is your favorite flower? *

What are some of your favorite smells? *

Are you aware of what 'Love Language' best pertains to you and/or your partner? If not, I ask that you visit http://www.5lovelanguages.com to do the quiz. Once you have this information, please relay it back to me. This helps me immensely to provide the support that will resonate most effectively with your individual needs & desires. *

If you were to describe your 'perfect' birth, what would it look like? Pay special attention to details. How would you want to FEEL? *

If your partner were to describe their 'perfect' birth, what would it look like? Ask them to pay special attention to details. How would they FEEL? *

If you were to describe your 'perfect' postpartum and introduction to parenthood, what would it look like? Pay special attention to details. How would you want to FEEL? *

If your partner were to describe their 'perfect' postpartum and introduction to parenthood, what would it look like? Ask them to pay special attention to details. How would they FEEL? *

Are there any special considerations you would like me to factor into the type of education, support, and guidance I will bring to you? This might include considering a history of abuse and/or trauma, religious or cultural factors, etc. *

How you ever worked with an energy healer before? *

Yes

Required

What are your favorite forms of self-care? *

Please sign your name & date *

Thank you sweet one!

I am truly looking forward to getting to know you better, and serving you as your sacred birth keeper!

Big Love,
Taraney Nicole

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