Intake form

Name

First Name

Last Name

Partner’s Name:

Any other support person attending the birth:

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Age:

Where do you plan to give birth?

Name of Providers:

Expected Date of Delivery

YYYY

Occupation:

History : Have you ever been pregnant before? (Please include abortions and miscarriages)

If you have been pregnant before, did you experience any complications with the pregnancy, birth or postpartum period?

Do you have any medical conditions that you feel may affect your pregnancy, birth or postpartum period?

Is there anything else you would like to share with me from your past?

Have you experienced any complications with this pregnancy?

Have you had any prenatal testing? Which tests?

How are conversations going with your provider?

Have you taken a Childbirth Education class? If yes, when and name of class: If not, do you plan to?

What resonated with you about the Childbirth Education class?

Describe your ideal vision for your birth?

How do you want to feel during and after the birth?

How do you want your baby to feel during and after the birth?

What are your thoughts about pain management during labor?

How do you think your partner will do during the birth?

What do you imagine would be really helpful during the birth coming from your doula? Your partner? Any other expectations from your support team?

What preferences do you have for immediately after the birth?

Are there any referrals you would like from me at this time?

Do you feel like you have community for support in the immediate area?

What are you most looking forward to about being a parent?

What fears do you have about early parenthood?

Are you taking a breastfeeding and newborn care class?

Do you know about the benefits of postpartum doula care?

Anything else you would like me to know?

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