Client Intake Form

Client Intake Form
Your Name *

First Name Last Name
Birth Partner's Name

First Name Last Name
Doctor/Midwife/Practice Name *
Hospital, Birthing Center, or Place of Delivery *
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
Phone Number

Area Code Phone Number
Your Baby
How many weeks pregnant are you?
Estimated Due Date *

Month Day Year
Date
Baby's Name (if known)
Planned Method of Feeding

Breastfeeding Formula Feeding Both Not sure, but would like more information
Your Health
Medical History
Any allergies?
Any current complications, restrictions, or medications?
Any history of Mental Illness?
Birth Preparation
Have you ever given birth before? *

No Yes, Vaginally only Yes, Cesarean only Yes, Vaginally and Cesarean
What is your birth plan for this pregnancy? *

Undecided Vaginally Cesarean
Have you taken or do you plan on taking any Childbirth Education classes? If so, which classes and where?
Please list any class you have taken or plan on taking.
Who do you plan to have assist you in labor? (check all that apply) *

Partner Doula Parent/InLaw Sibling Friend
Who do you want present for the delivery? *
Do you have a birth vision planned? *

Yes, it is finalized Yes, but would like some help with it No, but would like some help creating one No, not interested in one
How do you feel about interventions in labor/delivery?
What type of pain management are you looking to have? *

Non-medicinal comfort measures IV Medication Epidural
What type of comfort measures would you like to use in labor?

Distractions Breathing patterns Massage Birth Ball Walking, Dancing, Swaying Water (tub/shower) Visualization/Imagery Rebozo Aromatherapy Music
What is your vision for this birth? *
What is your plan for your placenta?

Placenta Encapsulation Lotus Birth Delayed Cord Clamping Cord Blood Bank None of the above Not sure, but would like more information
What are your expectations of me as your Doula? *
Are you looking for postpartum support?

Yes, please discuss my options with me Not interested Not sure, would like more information
Any other questions or concerns?
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Client Intake Form

Your Baby

Your Health

Birth Preparation