Doula Client Intake Form
OH MY GOSH, I can't wait to support you through this AMAZING experience! I know we've already gone through many of these questions, but I like to keep this in my confidential records so I can refer back to it or in case your information gets deleted from my phone 😃
Your Exact Home Address *
Please include your house number, street name, city and zip code.
- {name}
Home? Hospital? Hospital name? Please include the city too 😊
Which payment platform would you like to use? *
After payment is made depending on which platform you use, you'll receive an invoice/receipt for your records.
- Cash
- Venmo
- Apple Pay
- Zelle
- PayPal (credit card)
- FSA/HSA fund
- Not sure yet
What baby number is this? *
- #1
- #2
- #3
- #4
- #5
- #6+
Do you have a partner or support person? *
- Yes
- No
If I can't get ahold of you and I know you're in labor who should I call? *
Leave their name and phone number here please.
- {name}
Which Doula package are you receiving? *
- In-person support
- Everything but the birth
- Virtual support only
- Not sure yet
Planned mode of birth? *
Obviously, plans can change but I'd like to know where we're starting so I can support you accordingly 😊
- Vaginal
- Scheduled C-section
- VBAC
Do you have any allergies *
I use essential oils and herbs (examples: lavender, citrus, clary sage, arnica massage oil) during your support, and want to make sure I don't offer anything you might be allergic to.
- Yes
- No
If you have any existing or pre-existing health conditions please list them here.
Examples: Diabetes, gestational diabetes, broken bones, previous surgeries, pre-eclampsia, and so on...
- {name}
Sometimes I use screenshots of our messages as a review, Are you okay with me using that if I don't use your last name? *
I'd never share personal information that is confidential to you without your permission.
An example of what I might screenshot would be something like, "Thank you so much Petra, your support was so helpful."
I don't always use screenshots but if I do I want to make sure its okay with you first.
- Yes
- No
- Yes but show me before you use it
I'm not a professional photographer but I can take photos or videos of your labor and birth when possible. Is that something you'd like? *
If I take a photo on my phone I will delete it once I send it to you.
We can also chat more in-depth about this in our prenatals too if you'd like.
- Yes
- No
- Not sure yet
Are there any religious or cultural practices you'd like honored? *
If yes, please specify.
- {name}
Have you ever felt unsafe in a sexual encounter?
You don't have to answer but I ask in case you have some trauma that needs to be worked through before you give birth as birth can bring trauma to the surface and hinder labor progression.
Totally optional though, please don't feel obligated to answer if you aren't comfortable sharing with me.
- {name}
What are your hobbies or interests? Tell me yours and I'll tell you mine 😉
Example: Swimming, knitting, painting, hiking, or whatever else comes to mind
- {name}
Anything else you think might be important for me to know about you:
- {name}
Do not submit passwords through Airtable forms. Report malicious form