Client Intake Form

Please set aside a few minutes to complete this intake form prior to our first prenatal to help me gather some details about you. I am happy to go through any portions of the intake in person if that feels better for you.

Client Intake Form

Parent's Name

please also include pronouns

First Name

Last Name

Email Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Estimated Delivery Date or Baby's Birth Date

YYYY

If you have other children please list their name/age

Who is your current care provider

Please mention OB or Midwife's name and their practice name

Planned Birth Location

(home, hospital) or undecided

Type of Support you are looking for

Select all that apply.

Birth Doula

Postpartum Doula

Infant Feeding Support Consultation

Baby Wearing Consultation

Partner Name (if applicable)

Please list your partner's name (if Applicable), or mention if you have a special person who you are sharing your pregnancy with so I can get to know you and your support system better.

First Name

Last Name

Partner contact information (if applicable)

Please share with me your partner or support person's name/pronoun/contact info (if applicable). Please also mention where they live if they do not live with you. If there is anything else specific you want me to know about your partner/support person, you can mention it here as well. If not applicable, you can write NA.

Baby name(s)

If you are keeping it a secret until after the birth, then leave this blank.

First Name

Last Name

Who do I thank for referring you to me?

Family/parental leave plans

How long do you see yourself and/or your partner taking time off from work? Is there any family or close friends visiting or planning on staying close by that plan on coming over and helping out? In what capacity?

Do you have a postpartum plan?

Do you have allergies?

Please include any food/ medication/latex allergies for anyone living in your home. if none, please write NA.

Do you have any dietary restrictions or specific cooking needs?

Please include anyone who lives in your house. Examples could be that you strongly do not like peppers, or you are vegetarian, allergic to peanuts, etc.

Are there any medical issues/limitations/things you want to be acknowledged, or concerns I should know about to better serve you?

Your response can include about your partner/support person as well. If you want to make a note to discuss this outside of the intake form another time, that is okay too. Sometimes these type of topics are more suitable to discuss in person in a dialogue.

Any other questions/concerns/comments for me to address

If you have anything to share with me or question for me please enter here.

If you already have given birth, did you have a doula? What were the aspects you want to have repeated, and what were things you would want to be different- about the doula support and/or with care provider

Do you have any religious/ spiritual/ cultural preferences you want me to be aware of?