Client Intake Form

Name *

First

Last

Partner's Name

First

Last

Address

Phone Number *

Email *

Healthcare Provider *

Place of Birth *

Total Number of Pregnancies including this one *

Any history of fetal loss or infant loss? *

Have you experienced any complications with pregnancy? *

Yes
No

Number of previous vaginal deliveries *

Number of cesarean births *

How did each of your labors begin? *

Did previous births happen before, on or after your due date? *

Length of time for labor(s)? *

Did you experience any complications during labor or birth? *

Have you breastfed *

Yes
No

Have you had positive breastfeeding experiences? *

Yes
No

Have you attended childbirth classes or do you plan to attend? *

Yes
No

Do you plan to breastfeed? *

Yes
No

Are you currently experiencing any specific health or other concerns that affect this pregnancy? *

How do you see the role of your doula? *

During labor and birth, emotions associated with prior sexual abuse can come to the surface. As your support, it may be helpful for me to be aware if this issue exists and what your triggers are or may be. As with all of your information, any information you share will be kept confidential.

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