Client Intake Form
I am looking forward to supporting your birth experience!
Best Certified Doula
Birthing Parent Name *
Partner's Name
Due Date *
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Address *
Phone Number(s) *
Email *
Healthcare Provider *
Where are you giving birth? *
Prior Pregnancy and/or Birth Experiences: Total number of pregnancies, including this one? *
Any history of fetal or infant loss? If so, please explain.
Have you experienced any complications with pregnancy? If so, please explain.
Number of previous vaginal deliveries? *
Number of previous cesarean births? *
How did each of your labors begin?
Did previous births happen before, on or after your due date?
Length of time for labor(s)?
Did you experience any complications during labor or birth?
Prior Breastfeeding Experience: Have you breastfed? *
Did you have a positive breastfeeding experience?
Preparation for Birth: What childbirth class have you or will you attend?
Will you be breastfeeding? *
Are you currently experiencing any specific health or other concerns that affect this pregnancy? *
How do you see the role of your doula? *
During labor and birth, emotions associated with prior sexual abuse can come to the surface. As your support, it may be helpful for me to be aware if this issue exists and what your triggers are or may be. As with all of your information, any information you share will be kept confidential.
Is there anything else you would like me to know about you and your family?
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