The Wonders of Birth- Doula Services Intake Form
Congratulations! A new baby brings so much joy to a family! I am so pleased you desire to learn more about my doula services. Filling out this form ahead of time will help me cater your initial, free, no-obligation consultation as well as your prenatal visits to your specific needs! This is something my clients have come to love about my services. I do not have a "one-size-fits-all" approach, but rather a holistic, family-centered approach that is specific to each client and her loved ones.
In order to for me to add your birth to my calendar, you will need to fill out and sign my contract as well as pay a $200 deposit. Many clients handle this in person, but there are times when clients wish to complete this ahead of time and digitally (as my calendar space is limited). If you know you want to work with me before meeting, I am able to make a copy of my contract for us to sign digitally and you may pay your deposit through Paypal or by mailing a cashiers check/personal check payable to Karen Gartner.
The remaining $500-$600 (depending on your location and birthplace) may be paid by cash, check or Paypal (major credit cards are accepted through Paypal) either in one lump sum or through installments. The full fee must be paid by 34 weeks gestation. If you have any questions about this policy, please contact me (704) 980-8973. If you have a Health Savings Account (HSA) or Flexible Spending Account (FSA), you should be able to be reimbursed for part or all of the fee. Please contact your specific company to inquire whether doula services are reimbursable through your account.
If you are a member of an insurance alternative known as a "Healthcare Sharing Ministry" (such as Samaritan Ministries) you may qualify for a partial reimbursement.
I will not share your information with anyone else. Your information will be kept secure and private and is never used for advertising purposes.
Here is the link to my Explanation of Doula Services Form: https://docs.google.com/document/d/1gnuuuntvwYyZRrd8wqIVGa1JGZKorhCA60loF_44OAI/edit?usp=sharing
Here is the link to my Doula Services Client Agreement:
https://docs.google.com/document/d/1qHXZUgo7lu35OYtOC7a6NLH4-wOD-oCMHCKna2FnoP8/edit?usp=sharing
Name *
Your answer
Spouse or Partner's Name (optional)
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zipcode *
Your answer
Email Address *
Your answer
Partner's Email Address (if applicable)
Your answer
Phone Number *
Your answer
How would you like to sign the Client Agreement?
When is your anticipated due date? *
MM
/
DD
/
YYYY
What number pregnancy is this for you? *
Your answer
How many children do you currently have? *
Your answer
Who is your caregiver? *
Where do you plan to give birth? *
Your answer
Have you have any complications/concerns during your current pregnancy (please specify)? *
Your answer
Have you had any complications during any previous pregnancies (please specify, if not applicable, put N/A)? *
Your answer
Describe your previous births (if applicable, if not applicable put N/A) *
Your answer
Where do you like to be touched (anywhere not checked I assume you do NOT like to be touched there)? *
Required
Do you have specific comfort measures you think you will want me to use? If so, please check those you may be interested in (if you don't check something, that doesn't mean I won't offer it, but I will start with offering the things you find most helpful). *
Required
Do you have special birth wishes you would like me to remind you about during labor/birth (i.e. no episiotomy, no forceps/vacuum assisted birth, immediate skin to skin, delayed cord clamping, delayed routine newborn care, immediate breastfeeding, no IV, no pitocin, no interventions unless necessary, would like to labor at home as long as possible etc.)? If you have a Birth Wish List or Birth Plan, please email a copy to makebirthbetter@gmail.com *
Your answer
Do you have a history of abuse? (this question is optional and all information is confidential, however it can help me in working with you to know this information).
If you have been in an abusive relationship/situation, please describe the type of abuse-physical, emotional, sexual (optional, but extremely helpful for me to help you in your labor/birth):
Your answer
Have you had or are you currently taking childbirth preparation classes? *
Do the childbirth classes cover ways of handling pain in childbirth to your satisfaction? *
What topics are you most concerned about as you contemplate your upcoming labor, birth and/or postpartum? *
Required
Please list any other thoughts/concerns you would like to share with me (if not applicable, put N/A):
Your answer
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