Doula Service Form Client Information * Please fill out the information below. If any section does not apply, please leave it blank. First Name Last Name Nickname (Optional): Email * Phone * (###) ### #### Preferred Method of Contact Email Text Messages Phone Call Partner Information * First Name Last Name Nickname (Optional): Email Phone * (###) ### #### Preferred Method of Contact Email Text Messages Phone Call BIRTH INFORMATION This section helps us understand your expectations and preferences for the birth. Please provide as much information as you can. Estimated Due Date * MM DD YYYY Birth Location Name & Address: Sex of the Baby (if known) Name of The Baby (if Decided) Healthcare Provider Information Healthcare Team/Provider Name If you still need to choose, would you like to discuss options that may fit your birth needs? Yes No How are conversations going with your Healthcare Team/Provider? Do you feel heard, respected, and given time to ask questions and share concerns? Yes No What are your thoughts and/or fears about pain in labor? What information have you received on labor pain and its management? How have you planned to manage labor pain for your desired birth outcome? Pregnancy and Birth History This section collects details on past pregnancies and preferences affecting your current pregnancy and birth. Your answers will guide us in offering personalized care. Text Area What number of pregnancies is this for you? 1 2 3 4+ If you have had previous pregnancies/births, please indicate the outcomes below: Check all that apply and specify the number if applicable. Abortion Cesarean (C-section) Loss Multiples (e.g., twins, triplets) Vaginal Births VBAC (Vaginal Birth After Cesarean) Do you have any health conditions, allergies, or medical orders that could affect your pregnancy or postpartum period? Birth Preferences and Health Information Positive Aspects to Repeat/Incorporate: What elements from previous births or stories from other mothers would you like to experience or include in your birth story? Changes and Preferences: What would you like to handle differently in this birth? Are there specific practices or approaches you prefer? Personal and Spiritual Considerations: How do your history, coping abilities, and spiritual or cultural beliefs influence your birth plan? Postpartum Plan This section will help us understand your past experiences and hopes for the postpartum period so we can provide tailored support. Could you summarize your postpartum experience, what aspects you want to remain unchanged, and how you envision an improved postpartum experience? Do you have a supportive community in the area? Yes No Are you interested in Postpartum Doula Services? Yes No How would you like to feed your baby? Please check your preference) Nursing exclusively Exclusively pump Mixture of both Formula Combination of all Would like to learn more What are your biggest fears/concerns about the postpartum period? Are you taking or will you be taking prenatal classes? yes No If yes, where? Would you like suggestions for classes? (Childbirth, breastfeeding, newborn care) Yes No What labor techniques or methods have you considered and would like more information about? Doula Support Expectations and Birth Team Dynamics Please fill out the information below. If any section does not apply, please leave it blank. What is your idea of the role of a doula, or what expectations do you have? What is most important to your partner concerning my role as a doula? Who else, besides your partner, will be present at your labor, and do you feel comfortable and supported by their decisions? Do you want me to know anything else as we begin working together? Thank you!
