Doula Intake

“That’s the thing about birth, we don’t get an itinerary. We have to surrender and let go and it’s in that vulnerability we find the courage and strength we forgot we’ve had since our own birth. The power is already in you.” - Janurary Harshe

 
Client Name *
Client Name
Cell Phone
Cell Phone
Partner Name
Partner Name
Are you happy with your OB/Midwife?
i.e. therapists, acupuncturist, etc.
Medical Information
General Information
This may be triggering, take time to respond, or in person alone, or maybe you’re not quite ready at all, and that’s okay too.
Past Trauma Information
The following questions are solely informative. Honest answers will help us to better understand your needs and help you while you labor. In the event that you do not want to put these answers down on paper, please phone your doula or you may send these answers in a separate email directly to your doula. WE DO NOT SHARE THIS INFORMATION.
Please elaborate.
Please elaborate.
Please elaborate.
Anticipated Birth Information
water, massage, visualization, pain medication, etc.