Full Spectrum Doula Services Name * First Name Last Name Email * Phone * Certificate Code Doula Support Client Intake Form Pregnant Person Full Name First Name Last Name Pregnant Person Email Address Pregnant Person Cell Phone Partner or Support Person Full Name (if applicable) First Name Last Name Partner or Support Person Email Partner or Support Person Cell Phone If you have other children please list names and ages Estimated Due Date or Date of Birth Care Provider Place of Birth Type of Delivery (planned or actual) Have you taken Prenatal Classes (breastfeeding, newborn care, etc.) What are your primary goals for having a postpartum doula? Why is investing in an overnight postpartum doula important to you? How do you plan to feed baby or babies? * Are there any medical concerns you feel I should know about? Do you have a history of depression or other emotional disorders? Are there any known allergies in your family? Do you have any fears about your upcoming birth, postpartum, or parenting? Are You Taking Time Off Work? * Yes No If yes, how much time? Is your Partner or Support Person taking time off? Yes No If yes, how much time? Do you have pets in the home? What kind? Does anyone smoke in the home? What does your dream postpartum journey look like? Tell me how you imagine this… If you were your baby how would you like your postpartum doula to be characteristic wise? This could be someone warm, soft, quiet, loving, etc. Think about it, and tell me WHY? How do you know if a doula is right for you? Do you feed off energy and vibrations? Knowledge? What emotions are important to you, how do you want to feel during your postpartum journey? Do you want to feel supported, nurtured, loved, grounded, powerful? How do you NOT want to feel? How did you find about the overnight postpartum services? What made you think “This is what I want!”? What movies, books, or blogs have you been interested in to prepare you for this baby? Anything else that you feel is vital for me to know about you? Or anything you would like to share? Thank you!
