Your Mama Tribe Doula

New Client Intake Form

Thank you for taking the time to fillout the new client intake form. The information you provide will help me serve you to the best of my abilities. Please fill it out each item the best you can. Any questions you may have can all be answered during out visits.

Estimated Due Date

MonthDayYear

Mother's Name

First NameLast Name

Mother's Phone Number

Area CodePhone Number

Partner's Name

First NameLast Name

Partner's Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail

Additional Phone Number

Area CodePhone Number

Where are you delivering?

Your Doctor/Midwife

Prenatal tests? Please list:

Are you high risk?

Reason?

Your childbirth education history:

Please specify the childbirth education you have or that you intend to take.

Medications, Herbs, Vitamins:

Other Therapies: (homeopathy, acupuncture, massage, chiropractic, etc...)

Books read:

History:

Infertility Treatments:

Number of Pregnancies:

Number of Miscarriages:

Other Children:

Name

DOB

MonthDayYear

Name

DOB

MonthDayYear

Delivery Experience:

Length of Labor

Method of Pain Management?

Medical interventions: (pitocinm cervical ripening agents, suction, forceps, etc...)

Your thoughts and feelings on the birth(s)?

Client Profile:

What type of childbirth are you expecting?

On a scale of 1 to 10, how painful do you think birth will be for you?

What has influenced your expectations of labor? (Relatives? Friends? TV?)

What fears or concerns do you have around labor and delivery?

What kind of support do you expect from your Doula and partner?

In general, where do you feel tension in your body?

How do you regain calm during times of stress?

What kinds of things do you find helpful in times of stress or pain, i.e. cheering you on, massage, being left alone

For Partner: What strategies do you have for calming her down? How confident are you in your ability to do that?

What gives you confidence?

Are you having any major life stresses right now?

Personal or family history of depression or other mental disorders?

If yes, please describe briefly.

Religious affiliation/needs during labor?

Birth Preferences Information

This section is about what you would like to have happen during your labor and delievery. You may not have started thinking about or heard about some of the options listed here. That's OK. We can go over anything you are unsure of. This list can also be used to start the conversation with your provider.

During Labor I would like:

Please specify your aromatherapy scents preferences:

Labor

Once I am admitted, I would like:

As long as the baby and I are doing fine, I would like:

If they are available, I would like to try:

Specify "Other"

When it is time to push, I would like to:

I would like to try and/or I am open to trying the following positions for pushing (and birth):

Pain Relief

I would like to try the following pain-management techniques:

If I decide I want medical pain relief, I would prefer:

Vaginal Birth

I would like:

After birth, I would like:

Cesarean Section

If I have a cesarean section, I would like:

Postpartum

This section covers your preferences during the postpartum period. This is a good time to start thinking about the kind of parent you invision you'll become.

After delivery, I would like:

I plan to:

The following can be offered to my baby:

I would like:

For a boy:

For baby:

Transition Into Parenthood

Do you feel you have community for support in the immediate area?

What are you most looking forward to about being a parent?

What fears do you have about early parenthood?

Do you have any concerns about your (or your partner's) ability to breastfeed?

Do you know the benefits of Postpartum Doula Care?

Is there anything else you would like to know or share?