Partner Intake form

Name

First Name

Last Name

Birthing Person's Name:

Phone

(###)

###

####

Age:

Occupation:

History : Have you ever been a birth partner before?

If so, what was your experience like during the pregnancy, birth or postpartum period?

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

How are conversations going with your partner's care 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 you and your partner's birth experience?

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

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

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

What do you imagine would be really helpful during the birth coming from your doula?

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?

Anything else you would like me to know?

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