Doula Support Request
Thank you for taking a few minutes to fill out this form. Completing this form is the first step in determining if I am available for your baby's birth. Additionally, it will me get to know you better in preparation for your free consultation 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
Cell Phone number(s)
This is pregnancy #?
Estimated Due Date
Where do you plan on birthing?
Henry Ford - Detroit
Henry Ford - West Bloomfield
Providence Park - Novi
Providence Alternative Birth Center (ABC) - Southfield
Providence L & D - Southfield
St. Mary's - Livonia
Beaumont Oakwood - Dearborn
Beaumont - Troy
Beaumont - Grosse Pointe
Beaumont L & D - Royal Oak
Beaumont Karmanos Natural Birth Center (KNBC) - Royal Oak
Beaumont Botsford - Farmington Hills
Huron Valley Sinai Grace - Commerce Twp
Voigtlander Women's Hospital U of M - Ann Arbor
St. Joe's - Ann Arbor
Hutzel Hospital - Detroit
What type of birthing class will you take?
If you aren't sure, that's okay, we can talk about it when we meet
OB or Midwife Group/Name(s)
Briefly explain why you are interested in a doula-supported birth experience
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)?
If you have had a baby previously, please briefly describe the birth(s)
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.
Lastly, how did you hear about me?
I come to "Tranquil Touch" for massage therapy
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