Coastal Hypnobabies Doula Client Intake Form
Thank you for taking a little time to complete this form, and to make sure that I have all of your most up-to-date information. Please be assured that unless your specific consent is given, all things shared in the following form will be kept strictly confidential. Please feel free to contact me with any questions, as always!

Warmest Regards,

Melissa Furioli, HCHI, HCHD
www.coastalhypnobabies.com
760.703.5973
Email address *
Birthing Person's Name and Partner's Name: *
Your answer
Home Address, Phone Number: *
Your answer
Planned Location of Birth, Care Provider (Doctor, Midwife's name) *
Your answer
My Goals for this Birth: *
Your answer
Concerns that I have about this birth: *
Your answer
History of Physical or Sexual Trauma, Pregnancy Loss or Stillbirth (Please be as complete as possible, so I may best support you through this pregnancy and during your birth. As a reminder, all information provided will be kept strictly confidential. If none, please type 'none'): *
Your answer
Do you have plans to Breastfeed? If so, have you taken a Breastfeeding 101 class? *
Your answer
Anything else that you or your partner would like me to know:
Your answer
A copy of your responses will be emailed to the address you provided.
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