Client Initial Questionnaire
First Name
Your answer
Last Name
Your answer
Location
City/state
Your answer
Phone Number
Your answer
Email address
Your answer
What is your age?
Your answer
Estimated Due Date
MM
/
DD
/
YYYY
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?
Required
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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