Date
*
MM
DD
YYYY
Email
*
Name
*
First Name
Last Name
What are your pronouns?
*
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Partner's Name (optional)
First Name
Last Name
What are their pronouns?
Doctor/ Midwife's / Practice name
*
First Name
Last Name
Does your doctor/midwife know you are using a doula?
*
Yes
No
N/A
Location you desire for delivery
*
Are you using insurance for doula services?
*
Yes
No
Why are you seeking doula services?
*
What are your expectations of me as your doula?
*
If necessary, are you open to virtual sessions and birth assistance?
*
Now, a little about baby/babies
*
Estimated Due Date
MM
DD
YYYY
Baby's/babies' gender
*
Baby's/babies' name (if known)
*
Planned Method of Feeding
*
Now, about your general health
*
Do you have any allergies I should be aware of?
*
Explain any complications you have had with this pregnancy, any restrictions your caregiver has given you, and any medications you are currently taking.
*
How many pregnancies have you experienced?
*
Have you given birth before?
*
Have you taken or are you planning on taking any childbirth education classes? If so, what are they and where are you attending them?
*
Please list any other classes you have taken or plan on attending.
In addition to a doula, who do you plan to have assist you with your labor?
*
Who else do you want present for the delivery?
*
What is your vision for this birth?
*
Do you have a birth vision plan written down?
*
What type of pain management do you desire?
*
What type of comfort measures would you like to use in labor?
*
Any other questions or concerns?
