ELISE RUEL BIRTH SERVICES
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birth doula support

client intake form

Please fill out the following sections as completely as possible. 
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Thank you for taking the time to fill out this form. Having this information prior to our first prenatal appointment helps me to utilize our time together more effectively and serve you better. If you have any questions, please do not hesitate to ask.

Please note, this information is private and will not be shared with any parties without your express consent. 

    Additional Support Person (if you have one)


    Your Care Provider + Birth Location


    Your Health Information

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    Because of the unique challenges of birth, it is possible that a prior trauma or violent incident can impact your birth experience. By being aware of this I can better serve you, however, please share only what you are comfortable with.
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  • Home
  • About
  • Birth Doula
  • Prenatal Education
  • Doula Grant
  • Contact