Mid-Iowa Doulas Client Intake Form

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Please fill out this information carefully. Leave blank any questions that you are not familiar with or any you prefer not to answer.

Name: *

Your Birthdate:

YYYY

Due Date: *

YYYY

Email Address: *

Your Occupation:

Street Address: *

City, State, Zip Code *

How did you hear about our Agency? *

Home Phone:

Cell Phone: *

Partners Name:

Partners Cell Phone:

Partners Occupation:

Doctors Name: *

Hospital/Birth Facility *

Services Booked

Platinum Package- All Services- $1800- (Birth Doula, Postpartum Doula (2 nights- 6 hours each, 2 days- 4 hours each), PE, CBE, Lactation Bundle, Belly Casting(white only), Henna Belly Tattoo($50 value), Belly Binding, Infant Massage Lessons= $1,800 (You save up to $473!!!)

Birth Doula- $550 -$850 (Depending on distance from Birth Doula and experience)

BIRTH ONLY- $375- (No Prenatals or Postpartum Meetings, Birth Doula for Birth ONLY)

Postpartum Doula- $25/hr daytime hrs(3 hour minimum), $35/hr night time hrs(4 hour minimum)

Prenatal/Postpartum ONLY Package-NO BIRTH- $200- (2 prenatal visits, one postpartum visit)

Placenta Encapsulation- $250 (price if NOT using a Doula, mileage may be added, offered by Shawna only)

Placenta Encapsulation- $200 (price if USING a Birth Doula also, offered by Shawna only)

Professional Lactation Consultation- Price Varies- (Offered by Beth Buchholtz only, make checks payable to Naturally Nourished Lactation): Phone consult- $10/ 20 mins, Prenatal In-Person Consult- $75, Hospital Visit Consult- $75, Postpartum In-Person Consult- $95, Bundled Package- $200 (Mileage may be added if only purchasing this service).

Professional Photography package: $350 if using MID Birth Doula. $250 if using Carmelita as your Birth Doula and Photographer together. $500 plus mileage if not using a MID Birth Doula at all. Includes 20 edited digital images, plus unedited digital images

Private Childbirth Education classes: $200

Belly Casting- $75-$150- depending on design (Offered by Shawna only)

Belly Binding- $75 to rent and $150 to buy

Henna Belly Tattoo- $50-$150 depending on size and time

Infant Massage Lessons- $50 (Included FREE with the purchase of a Birth Doula, offered by Shawna only)

Other:

If you are doing Placenta Encapsulation, do you want a placenta print(aka "The Tree of Life") and cord keepsake? (No extra charge)

Yes

Clear selection

Sex of baby(if known):

Boy

Girl

Unknown

Clear selection

Have you taken any childbirth preparation classes?

In general, how have you felt with this pregnancy?

Please list the people you plan to have present at your birth:

Do you plan to breastfeed this baby?

Yes

Clear selection

Do you have herpes? *

Yes

Do you have an STD? *

Yes

If yes, please list your STD's

Have you tested positive for Group B Strep?

Yes

Not tested yet

Clear selection

Anything else you would like me to know about your history, fears, limitations, dreams, hopes about your birth?

Number of pregnancies?

Number of births?

Abortions?

Miscarriages?

If you've given birth before, please answering the following questions...

Did you have a Vaginal Birth or Cesarean?

Vaginal

Cesarean

Clear selection

If Vaginal, did you use any type of medicated pain relief?

How much did your baby/babies weigh?

Were they born on time or early?

Did you breastfeed?

Yes

Still Breastfeeding

Clear selection

How long were you in labor for each baby?

How did your labor begin?

Did you have any complications during the labor or after the birth?

Older Children(s) Name(s)

What are your expectations of me as your Birth Doula? *

Submit

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