Client Initial Questionnaire
First Name
Your answer
Last Name
Your answer
Your answer
Phone Number
Your answer
Email address
Your answer
What is your age?
Your answer
Estimated Due Date
Who is your Doctor/OB/Midwife?
Your answer
Where will you be giving birth?
Your answer
Do you have a supportive partner that will be at the birth?
Is this your first pregnancy?
If you have had a prior birth, was it:
Why do you want the help of a doula?
Have you taken a childbirth education class?
What is your living situation?
Do you feel safe in your living situation?
Are you a recently settled (2 years or less) immigrant or refugee?
If yes, where are you from?
Your answer
What languages do you speak?
Do you need the help of a translator?
What is your religious affiliation?
What is your weekly income before taxes?
(This information is confidential)
Your answer
How many people does this income support?
(example: you and your partner= 2 people)
Your answer
Is there anything else you would like to tell us about yourself that would help us match you with a doula?
Your answer
How did you here about our program?
Your answer
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