Doula Client Questionnaire
Thank you for taking a few minutes to fill out this form. It will help me get to know you better in preparation for our meeting to discuss your desires in having a doula-supported birth experience. Please feel free to include any questions you would like me to be ready to answer when we meet. Thank you so much! Exie Buehler LMT, BCTMB, ACMT, CLD (CBI), Dip CBEd
You & Your Partner/Significant Other/Spouse's Name *
Your answer
Address *
Your answer
Cell Phone number(s) *
Your answer
Email Address
Your answer
This is pregnancy #? *
Your answer
Estimated Due Date *
MM
/
DD
/
YYYY
Where do you plan on birthing? *
What type of birthing class will you take?
If you aren't sure, that's okay, we can talk about it when we meet
Your answer
OB or Midwife Group/Name(s) *
Your answer
Briefly explain why you are interested in a doula-supported birth experience *
Your answer
Please share any birth exposure you have had *
For instance: Have you ever personally attended a birth (friend/family/other)? Do you watch birth-related TV shows (ie. Birth Story) or seen videos of birth? What kinds of birth stories have you heard (positive or negative)?
Your answer
If you have had a baby previously, please briefly describe the birth(s) *
Your answer
Please list any questions you would like me be prepared to answer when we meet
If you can't think of anything now, don't worry. Often questions develop and are answered during our discussion.
Your answer
Lastly, how did you hear about me? *
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