Client Intake
You're going to have a baby! Wow, how wonderful! I'm honored you would consider having me support you at such a special time. Please complete the following forms to allow me to serve you to the best of my ability. This form has the potential to take time and you may want to consult your Birth Partner.
First Name
Last Name
How did you find out about Little Arrows
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Your Contact Number
Your Date of Birth
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DD
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Birth Partner First Name
Birth Partner Last Name
Contact Number for your Birth Partner
Who is your Birth Partner
Guess Date (Due Date) *
MM
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DD
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YYYY
Planned Birthing location
OBGYN, Midwife (CPM, CNM, LM)Family or Practice MD. Please state which and Name.
Practice Name
Home Address Line 1
Address Line 2
City
State
Zip
Your Email address *
Home Number
Cell Phone Number *
Do you know your baby's gender
Clear selection
Baby's Name if known
How do you plan to feed your baby
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Please list any health concerns that may impact your pregnancy/labor/delivery
Do you have any allergies
Please list any complications that have arisen during this pregnancy, any restrictions your caregiver has provided, and any current medications you are on
Have you given birth before
How many births
Number of pregnancies
Number of living children (not including this pregnancy)
Have you or are you planning on taking any Childbirth Education classes
Please let me know what other classes you have taken, if any
Who do you plan to assist you with your labor
Who do you want present for the delivery
Do you have a Birth Vision planned
What type of pain management are you considering
What type of comfort measures would you like to use during labor
What is your vision for this birth - you 3 most important things
What are your expectations of me as your Doula
What are your dislikes, this is very important, think verbally and physically. This will allow me to help create the best possible environment for you.
Please state any wishes you have for immediate care of your baby. First 24 hours. Please list.
Please comment anything else you would like me to know.
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