Doula Clients

Doula Client Intake Form

April Lovett is collecting this information as it pertains to your case only.
She will never divulge your private information to anyone without your express consent.

Mothers Name: *

Mothers Phone Number: *

Partners/Support Persons Name (is applicable) *

Partners or Support Persons Phone Number (if applicable) *

Preferred Email Address: *

Clients Home Address: *

Estimated Due Date: *

Care Provider: *

Planned Location of Birth: *

Back up hospital (if birth center of home birth): *

Who else will attend the birth? *

Have you attended childbirth classes? If so, when and with whom? *

Do you plan on breastfeeding? *

Yes No Maybe

Have you attending breastfeeding classes? *

Do you have any concerns about breastfeeding? *

Do you have a birth plan written? Have you reviewed it with your caregiver? If you have a plan, please email me a copy. I can also provide materials to help you in exploring your options and creating a birth plan. *

Planned role for the doula: *

Photography/Video Planned? *

Yes No Maybe

Do you have any children? *

Have you been pregnant before? *

Yes No

Are you receiving care for any other physical or mental health issues? *

Have you or any family members experienced postpartum depression before? *

Have you experienced any complications with this pregnancy? *

Are you experiencing any discomforts? *

Because of the unique challenges of birth, it's possible that a prior trauma or violent incident can impact your birth experience. By being aware of this I can better serve you, and any information you choose to share with me will be kept absolutely confidential. Due to the sensitive nature of this topic we can discuss this during our visit, or if you prefer you may share any concerns below. (This question is optional) *

Is there anything else you want to share about your physical or emotional health related to your pregnancy and birth that will help me better serve you? *

If you have a current partner, what do you hope their role will be in your birthing experience? How do you think they will support you in your goals? *

How do you respond to stressful situations? *

Is there anything I should be aware of as your doula in order to provide you the best possible care? *

What do you hope for your doula to add to your birthing experience? *

Do you have any special concerns or questions you would like us to discuss during our visit? *

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