Intake Form | SEA Doula Specialist

Birth Client Intake Form

First name

Last name

Phone

Please tell me your due date and where you plan to have your birth (include birthing center/hospital information).

Please tell me about your preferences and goals for your labor and delivery. Do you have a birth plan?

Who will be attending your prenatal visits and birth? What roles will they play?

How have you prepared for your birth? (Examples: prenatal yoga, childbirth education classes, lactation consulting, etc.)

How is your relationship with your Midwife/OBGYN? Please provide their contact information so I can have it on file.

How do yoy envision a doula supporting you throughout your pregnancy and birth experience?

Please enter the contact information of the people you want me to have on file so I can reach out to them on your behalf if it becomes necessary for any reason.

What other information do you want me to have about you? (Any extra information you feel comfortable sharing about your family, past pregnancies, birth history, pertinant health history, etc.)

Thank you for taking the time to fill out an intake form!

We will discuss the information you've provided further when we meet for our first Prenatal Visit.