Birth Doula Intake Form

Name:

Email Address:

Your DOB:

Your Telephone Number:

Your Spouse/Partner’s Telephone Number:

Your Spouse/Partner’s Name:

Your Children’s Name/Age:

Your Address:

Yours & Your Spouse/Partner’s Professions:

When is the estimated date of arrival for your little one(s)?

Who do you plan on having support you and attend your birth?

What is the name of the practice or care provider you are working with?

Where would you like to deliver?
HospitalHomeUnsureOther

If you plan on delivering in a hospital, which hospital?

How have you been preparing for this birth/having a newborn thus far?

Have there been any complications so far?

Is this birth a planned VBAC or C-Section?

Have you decided which Health Care Provider your baby will be seeing?

What are your feeding desires?

What kind of childbirth are you expecting (fears/hopes/concerns/goals)?

What kind of support are you expecting from your Doula and your partner?

In general, where do you feel tension in your body? Head, neck, chest, back, jaws, shoulders, legs, etc?

How do you manifest bodily tension? Racing Heart, clamminess, butterflies in your stomach, trembling hands, nausea, tapping feet, difficulty breathing, biting fingernails, clenched fists, sweating, trembling legs, grinding teeth?

How do you regain calm during times of stress? Deep breathing, visualizations, deliberate relaxation, information gathering, reassurance from others?

What are your major life stresses at present?

What is your plan for postpartum care? Do you have a built-in social support system? Are there particular things you would like/need to be covered prior to and after the baby arrives?

Is there a personal or family history of depression?

Do you have a religious affiliation?

Do you have any questions or comments?

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