Step One: Client Intake Form

I am honored at the prospect of supporting you and your family in this sacred moment. Please take a moment to complete the below form. If you don't know or have an answer, we can come back to it.This is the first step in our working together and will help ensure our first meeting is productive and personal.

Client Name

First Name

Last Name

Client Email Address

Client Phone

(###)

###

####

Client Birthday

YYYY

Birth Partner Name

First Name

Last Name

Birth Partner Phone

(###)

###

####

Name or Nickname of Baby

First Name

Last Name

Baby's Estimated Due Date/Birthdate

YYYY

Gender of Baby

Your Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I am interested in

Birth Doula Services

Postpartum Doula Services

Meal and Nutrition Help

Other

Unsure

Family Members

Tell me who is in your family and will be part of your birth and/or postpartum experience in some way. And yes, pets count!

Hospital Name/Birth Center Name/Homebirth

Care Provider Name/Birth Practice Name

Additional Health Information

Please let me know if you have any conditions that may affect your birth (genital herpes, HIV, HPV, gestational diabetes, high blood pressure, or have tested positive for Group B Strep.)

Previous Birth Story

Please provide a short note summarizing your previous birth experiences. We will make time to discuss this in greater detail.

What are your expectations and goals?

Dream big!

What are your biggest anxieties or fears - if any?

Be honest, there is no judgement and I promise you won't scare me.

How can I best help you?

Just a quick description of how you see us working together - and it's ok to say "I don't know" :)

Anything we missed?

If the above didn't cover something you think is important for me to know before our first meeting, please share it here. Know that we will make time to go over all of this and so much more in our prenatal visits, should we decide to work together.

All information shared with us is considered confidential and never shared without your explicit consent.