This intake form is for new clients only. If you are not a new client of mine and have landed here by mistake, I would love to welcome you to any other page on my website!
To my new clients, welcome! I can’t wait to support you. Truly, every birth I attend is such a huge honor. This intake form will give me much more information in how I can best support you throughout your journey. Please give me as much or as little information as you see fit. If a question does not apply to you, feel free to leave it blank. This information may be shared with my backup doulas if needed for your care, but only on an as-needed basis. Let me know if you have any questions!

Name

First Name

Last Name

Preferred Name and Pronouns

First Name

Last Name

Estimated due Date

YYYY

Phone

(###)

###

####

Address

Date of Birth

YYYY

Will you have a partner present for this birth?

Partner’s Name

First Name

Last Name

Partner’s Preferred Name and Pronouns

First Name

Last Name

Partner’s Phone

(###)

###

####

Is there anything I should know about your relationship?

Do you have any pets I should know about? I love all the animals, I would just like to know all of your family!

Have you given birth before? What are your feelings towards your previous birth?

What are the names and ages of your children?

Please describe your previous birth experiences. (Induced, physiological, how long, how long did you push, any complications, etc.,)

Have you experienced birth trauma?

What are your thoughts towards this pregnancy?

Have you experienced a miscarriage/stillbirth/child loss before? What feelings come up for you when you think about it? Would you like to talk more about it or only have it brought up as needed?

How did you find out you are pregnant? What was your (and your partner’s if applicable) reaction?

Do you know baby’s name and gender? How are you feeling about baby’s gender?

Any pregnancy complications for this pregnancy?

Any pregnancy complications with previous pregnancies?

Why did you choose your birthplace and provider?

Have you experienced any sexual trauma? Feel free to give as much or as little info as you would like.

I strive to practice in a trauma-informed way. It helps if I have a little bit of history. Have you experienced any sexual trauma? Feel free to give as much or as little info as you would like. Please let me know if you would like to talk more about this in person or if you would like me to only bring this up as needed.

I bring my camera to every birth I attend. Are you okay with images being taken at your birth? Are there any images you do not want taken? Are there any images that are super important to you?

Is there anything I should know about your religion or spirituality?

Any allergies or dietary restrictions?

Favorite comfort food?

Anything you feel I should know?

How often would you like me to check in with you?

Is there anything you would like me to know about your sexuality?

I take on intern or "shadow" doulas who are learning through birth observation with Little Blooming Warriors. You may have met them at any of the classes you attended. Would you be comfortable with an intern shadowing me at your birth? This would be no additional cost to you and you would be able to have them attend one of our prenatals before the birth as well.

How can I best serve you (and your partner if applicable)?