Your Name
*
First Name
Last Name
Your Spouse's Name
*
First Name
Last Name
Email
*
Your Phone Number
(###)
###
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Your Spouse's Phone Number
This is helpful if your spouse may be the one to call or text me when you are in labor. If all communication will be going through your phone number then this one is not necessary.
(###)
###
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What services are you interested in?
Baby's Name
Baby's Gender
Boy
Girl
Suprise Gender
Your Address
If you would like for me to labor with you at your home.
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Did you take a birth class? If so which one?
If you could describe your dream birth what would it look like?
Do You Have Any Cultural or Religious Preferences You Would Like Honored During Your Birth?
How has your pregnancy been going?
How have you been sleeping at night?
How has your nutrition and exercise been this pregnancy?
Have You Had Any Past Trauma That May Affect Your Birth Experience?
(Anything you share will be kept confidential. You can share as much or as little as you desire. As your doula it could be helpful to know if there are particular triggers for you. But it is not necessary to know either.)
What Type Of Body Work Are You Currently Receiving?
(Chiro, PT, Massage Therapy, CST, etc)
How Do You Envision Doula Support During Labor, Birth, and Postpartum? How Can I Help Meet Your Expectations?
What Fears, If Any, Do You Have About The Birth Process, Postpartum, Or Parenting?
What Are Your Plans Or Preferences For Pain Management During Labor?
(ie non medical comfort measures, tens unit, nitrous oxide, narcotics, epidural, etc)
Who Would You Like Present At Your Birth And Immediate Postpartum? What Do You Expect Their Roles To Be?
Is There Anything Blood Born Communicable That I Should Be Aware of?
(No judgement zone. I just need to know for safety reasons.)
Please feel free to let me know anything else pregnancy, labor, or postpartum that you would like me to know.
