Doula Client Intake Form

New Client Intake Form

Nicky Dawkins - Full Spectrum Doula
Hello love! Congratulations on your pregnancy! Thank you for taking the time to fill out this form so we can get to know you better and have an idea of how to best support you during your journey through pregnancy, birth and postpartum!
Estimated Due Date*

MonthDayYear
Your Full Name*

First NameLast Name
Do you have a nickname you prefer?
Your Birthday*

MonthDayYear
Date
E-mail*
Your Best Contact Number*

Area CodePhone Number
Your Partner's Name (if applicable)

First NameLast Name
Your Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Is this your first pregnancy?*

YesNo
If you answered yes above, how long has it been since your last child was born?

6 months - 1 year1 - 2 yearsOver 2 yearsN/A
Have you ever experienced pregnancy and/or infant loss?*

YesNoI have recently or I am currently experiencing a loss
Are you having multiples? (twins, etc)*

NoTwinsTriplets or more
Doula Services interested in (check all that apply):*

Period RepairFertilityPrenatal Education & FitnessBirth & LaborPostpartum Recovery & Newborn CarePregnancy & Infant Loss Support (including abortion and/or loss of custody)Cannabis Education for pregnancy & postpartumOnline Reproductive and Maternal Health CoursesA la carte services (hourly or flat rate) (Vaginal Steaming, Prenatal/Postnatal Fitness, Kegel & Core Recovery, Breastfeeding Counselor, Newborn Sleep Support)Full Spectrum - I want it all!
Are you aiming to have an all-natural birth without intervention?*

YesNoI would like to learn more about my birth options
Are interested in having a water birth?*

YesNo
Midwife / Doctor - PLEASE COMPLETE. If you're still searching, type N/A*

First NameLast Name
Name of practice (if applicable)
Where do you plan to birth? (Hospital / Birthing Center / Home)*
Name hospital or birthing center. If you're having a home birth, please type N/A*
Hospital or birthing center address - PLEASE COMPLETE*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you currently have health insurance that covers Doula services?*

YesNoNot sure, but want to find out
If so, which health insurance do you have?
Please indicate if this is Medicaid or private. If none, please type N/A

MedicaidPrivateN/A
About your baby
Baby's name(s) (if known)
Baby's Gender

Don't know yet!BoyGirlBoth (Mulitples)It's a surprise!
Planned Method of Feeding

BreastfeedingFormula FeedingBothNot sure but would like more information
About your health
Please state your general health
Is your pregnancy considered high-risk? If so, why?
Do you have any allergies or sensitivities I should be aware of?
Explain any complications you have had with this pregnancy, any restrictions your caregiver has given you, and any medications you are currently taking.*
Any personal, financial, mental health or other issues you would like me to know that may have an impact on our work together?*
Preperation for Birth
Have you given birth before?*

NoYes,Vaginally onlyYes, Cesarean onlyYes,Vaginally and Cesarean
Are you considering a VBAC (Vaginal birth after c-section)

YesNoI need more informationN/A
Have you taken or are you planning on taking any childbirth education classes? If so, what are they and where are you attending them?
Please list any other classes you have taken or plan on attending.
Who do you plan to have assist you with your labor? (Check all that apply)*

PartnerDoulaMother/ Mother-in-LawSiblingFriendOther
Who do you want present for the delivery? Please list*
Do you have a birth vision planned?*

Yes, it is a final copyYes, but it is a draft and would like some helpNo, I would like some help writing one.No, I have no interest in one.
How do you feel about interventions in labor/delivery?
What types of pain management are you open to having during labor?*

Comfort measures and movementHolistic pain managementIV MedicationEpiduralI want them allI need more informationOther
What type of natural comfort measures would you be open to using in labor?

DistractionsBreathing PatternsMassageBirth BallWalking, Dancing, SwayingWater (tub/Shower)Hot/Cold TherapyVisualization/ImageryCannabis (CBD)Focal PointsAromatherapyMusicAcupressure
Will you be keeping your placenta?*

Yes, I would like to have my placenta encapsulatedYes, I will be encapsulating it myself or by another personNo wayI need more information about this practice
IMPORTANT!

If you would like to keep your placenta to assist you with postpartum recovery, you must clear it with you hospital or birthing center prior to delivering. I will be able to assist you will this process.
What is your vision for this birth? Name 3 of your most important things. *
What are your expectations of me as your doula?*
Any other questions, concerns or things I should know about?
Would you need help with any of the following support services? (check all that apply)*

Yes, I may need help with newborn care and/or postpartum care itemsYes, I may need help with finding childcare supportYes, I may need help with housing and/or foodYes, I may need help with mental health supportNope, we are good to go!
How did you hear about my services?*
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New Client Intake Form

IMPORTANT!