INTAKE FORM
Client Profile
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Name (First and Last) *
Phone number *
Email
Age *
Racial demographic *
Expected Due Date *
MM
/
DD
/
YYYY
Address *
Has your due date been changed?
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If Yes, Why?
Doula Preference? (Please choose 2) *
Name of OB/GYN or Midwife *
Do you have insurance? *
Who will be present at birth?
How do you plan to feed baby? *
Do you have any questions or concerns about child birth or breastfeeding?
Total number of pregnancies
Number of live births *
Previous pregnancy complications/discomforts and treatments
 Current pregnancy complications/discomforts and treatment sought
 Do you have any allergies, sensitivities or diet restrictions?  
 Medications you are taking (including prenatal vitamins):  
Ever taken a childbirth class? *
If yes, with who?
Add income  
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Where do you plan to deliver? *

On a scale of 1-5 how would you rate your overall emotional well-being right now?


Very Overwhelmed
Great
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