Client Intake Form
Name *
Email *
Address *
Phone number *
Due Date *
Do you have a history of miscarriage or stillbirth
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Have you received fertility treatments? If yes, for how long?
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Have you ever had a C-section? If yes, for what reasons?
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Who is your care provider? Midwife, OB, other. Please specify who you see below
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Where do you plan to have your baby? Home, hospital, or birth center
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What is the name of the hospital or birth center
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Do you have any prenatal complications with this pregnancy? If yes, please specify
*
Describe your occupation, how it affects your pregnancy, how long you plan to work, and if/when you plan to return to work postpartum.
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How do you envision your ideal birth scenario? What factors are important?
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Do you use natural remedies or complementary routes and focus on holistic practices, or do you approach things from a western standpoint/perspective first?
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What are you most hoping for support with?
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Have you worked with a doula or holistic practitioner before? If so, what did you appreciate or not appreciate?
Do you have any other medical conditions I should be aware of, including allergies to essential oils or honey?
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My services are an intentional investment in personalized, hands-on support. I work with a limited number of families at a time to ensure presence, availability, and quality of care. Have you reviewed my pricing guide, and does the investment align with what you are prepared to commit to? If yes, write "I understand" below.
*
When are you hoping to begin support?
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How did you hear about me?
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Please share anything further that you feel it is important for me to know
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Vaccination Policy

I do not receive routine vaccinations and do not take clients who require their doula to be vaccinated. This boundary is non-negotiable and part of how I choose to practice.

If this does not align with your needs or expectations, I may not be the right fit, and I fully respect that. 

*Does this align with your expectations for care?
 *
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