Client Intake Form

Client Intake Form
Your Name*

First NameLast Name
Birth Partner's Name

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

Street Address

Street Address Line 2

CityState / Province

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

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

MonthDayYear
Date
Baby's Name (if known)
Planned Method of Feeding

BreastfeedingFormula FeedingBothNot 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?*

NoYes, Vaginally onlyYes, Cesarean onlyYes, Vaginally and Cesarean
What is your birth plan for this pregnancy?*

UndecidedVaginallyCesarean
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)*

PartnerDoulaParent/InLawSiblingFriendOther
Who do you want present for the delivery?*
Do you have a birth vision planned?*

Yes, it is finalizedYes, but would like some help with itNo, but would like some help creating oneNo, 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 measuresIV MedicationEpiduralOther
What type of comfort measures would you like to use in labor?

DistractionsBreathing patternsMassageBirth BallWalking, Dancing, SwayingWater (tub/shower)Visualization/ImageryRebozoAromatherapyMusicOther
What is your vision for this birth?*
What is your plan for your placenta?

Placenta EncapsulationLotus BirthDelayed Cord ClampingCord Blood BankNone of the aboveNot sure, but would like more informationOther
What are your expectations of me as your Doula?*
Are you looking for postpartum support?

Yes, please discuss my options with meNot interestedNot sure, would like more informationOther
Any other questions or concerns?
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Client Intake Form

Your Baby

Your Health

Birth Preparation