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Relationship to birthing person

Do you have any other children in the family? If so please list their name(s) and ages

Main care provider & planned location of birth

Have you taken any Prenatal classes?

Please describe

What are your Primary goals for having a Postpartum Doula?

Are there any medical concerns you feel I should know about yourself or baby?

Do you have a history or depression or any other mental health disorders?

Any known allergies in the family?

Do you have any fears about your upcoming birth, postpartum, or parenting?

Will you be taking time off work? (if so how much?)

Will your support person be taking time off work? (if so how much?)

Do you have any pets in your home?

Does anyone smoke or vape in the house?

Anything else you would like to share?

New Client Intake Form