Birth Preferences Form

Birth Preferences Form
About You
Full Name
First NameLast Name
Preferred Name
Pronouns
Estimated Due Date (MM-DD-YYYY) — 2 digit month, 2 digit day, 4 digit year
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Birth Location (if known)
Doctor or Midwife
Client Email (e.g., example@example.com)
example@example.com
Doula Name
First NameLast Name
Doula Email (e.g., example@example.com)
example@example.com
Support People
Who would you like to support you during labor, birth, and immediate postpartum period?
Rows Name During Labor During Birth During Postpartum
Partner
Doula
Family member
Friend
Is there anyone you do NOT want present for ANY reason?
If yes, please list their name(s) here:
Is there anyone not listed above that you would like to receive updates about the birth?
Communication and Respect
Everyone communicates differently. Tell us what works best for you.
Spoken Language Preference
Interpreter needed
How would you like information shared with you?
I feel most respected when?
Emotional Safety
What helps you feel calm or safe during stressful moments?
Is there anything that may make you feel uncomfortable or unsafe? (Please Select; e.g., loud noises, certain touch locations)
Are there cultural, spiritual, or personal practices you would like honored before, during, or after birth? (Please Select; e.g., La cuarentena/quarantaine, lotus birth, specific prayer(s) in labor)
Labor Comfort and Pain Relief
During labor, I would like to try:
Other
Specific ways my doula can support me:
People choose many different ways to manage pain during labor.
Right now I feel:
Other
Other thoughts or concerns about pain relief:
Medical Care, Pushing & Birth
Sometimes medical care is needed to keep parents and babies safe.
When possible, I would like:
Other
If labor needs help starting or moving faster, I would prefer:
Other
When it is time to push, I would like to try:
Other
Right After Birth and Feeding Baby
If my baby and I are healthy, I would like:
Other
Who should hold the baby after me?
If a Cesarean birth is needed, I would like:
Other
If my baby requires more support or a NICU evaluation, I would like:
Other
My feeding plan right now is:
Other
I would like support with feeding from:
Other
Past Experiences and Support Needs
You can share as much or as little as you want.
Have you had any past birth or medical experiences that may affect how you feel about this birth?
How can your care team help support you?
Sometimes families need extra support during pregnancy or after birth.
Would you like help connecting with resources for:
Other
My Most Important Wishes and Final Thoughts
1. What matters most to you during birth?
2. What matters most to you during birth?
3. What matters most to you during birth?
Birth can be unpredictable. Plans may change. You deserve respect, clear communication, and compassionate care.
Should be Empty:

Select theme:

Rows	Name	During Labor	During Birth	During Postpartum
Partner
Doula
Family member
Friend

Birth Preferences Form

About You

Support People

Communication and Respect

Emotional Safety

Labor Comfort and Pain Relief

Medical Care, Pushing & Birth

Right After Birth and Feeding Baby

Past Experiences and Support Needs

My Most Important Wishes and Final Thoughts