Doula Intake Form (Part 2)
Please fill out as many questions as you can before we come together for our second meeting.
This information is private and respected, and will only be seen by you and me.
What is your highest hope for this birth, and how can I as a doula help you accomplish this?
Your answer
As your doula, I will be helping you stay nourished during labor. Do you have a personal 'meal/snack/drink' plan for during and immediately after birth?
What techniques for comfort and deepening during labor are you interested in using?
Interested
Not Interested
Don't know about this
Birth Ball
Rebozo
Hypnobirthing
Orgasmic Birth
Herbal Pain Relief/Relaxation
Water Birth
Dancing
Time alone with self or with partner
Massage
Aromatherapy
Walking outdoors/deep nature connection
Laughter and Fun
Epidural/Pain Medications
Song and sound
Do you have any ritual or ceremony planned for your birth? If so, how would you like me to be involved in this process?
Your answer
Here are a list of potential stressors at birth. Please answer as if you were imagining yourself in labor.
Very Stressful
Mildly Stressful
Not Stressful
Family dynamics (partner, parents, children)
Emergency Scenario that requires a hospital transfer
Emergency Scenario that does not require a hospital transfer
Pain
Lack of sleep/exhaustion
Your partner having a breakdown
Blood, lots of it
Nudity in front of others
Bright lights
Strong smells
Loud noises
Losing control
Have you personally experienced sexual, physical, verbal or emotional abuse?
If you responded 'yes' to the above question, would you like us to discuss this further and how it could potentially affect the birth process? (If you don’t want to speak about it, but merely want me to know that abuse did, in fact, occur, I will not pry further)
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