Birth Doula Intake Form

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Doula Grant
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birth doula support

client intake form

Please fill out the following sections as completely as possible.

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.

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Preferred Form of Communication *

Email Text Message Phone Call

How did you hear about Elise Ruel Birth Services? If you were referred, I would love to thank them! *

Additional Support Person (if you have one)

Name *

First

Last

Phone Number *

Relationship to you *

Your Care Provider + Birth Location

Type of Provider *

Provider Name *

Preferred Birth Location *

Hospital Name (if birthing in the hospital or in case of transfer from Home) *

Your Health Information

Estimated Due Date *

Is this your first pregnancy? *

Yes No

Please tell me about your previous pregnancies/births (as much as you feel comfortable) *

Do you plan to breast/chest feed? *

Yes No Undecided

Please take this opportunity to list any specific questions or concerns you have related to breastfeeding *

Do you have a birth plan prepared? *

Yes No

Can you share with me a bit about the type of birth you are hoping to have? *

Please take the opportunity now to list any concerns about your upcoming birth experience: *

Is there anything I should be aware of, as your doula, in order to provide the best possible care? *

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.

Do you have any other questions, comments or concerns? *

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Home
About
Birth Doula
Prenatal Education
Doula Grant
Contact

UA-170736849-1