Intake Questions ← BackThank you for your response. ✨ Client Information Full Name Preferred Name Date of Birth (YYYY-MM-DD) Age Phone number Email Address(required) Home Address Emergency Contact Name Relationship to Client Emergency Contact Phone Pregnancy Information Are you currently pregnant? Yes No Trying to concieve. Postpartum Estimated Due Date (EDD) (YYYY-MM-DD) How many weeks pregnant are you? Is this your first pregnancy? Yes No Number of pregnancies Number of births Number of miscarriages Number of C-sections Medical & Health History Do you have any of the following medical conditions? High Blood Pressure Diabetes Thyroid Disorder Anemia Asthma Depression Anxiety History of Postpartum Depression Any other medical conditions? Are you currently taking any medications? Yes No If yes, please list medications: Do you have any allergies? Yes No If yes, please list allergies: Do you have any current pregnancy complications? Yes No If yes, please explain pregnancy complications: Provider Information OB/GYN or Midwife Name Hospital or Birth Center Name Planned Birth Location Hospital Birth Center Home Birth Undecided High-risk pregnancy? Yes No Support System Do you have a partner or support person? Yes No Name of partner/support person Will they be present at birth? Yes No Unsure Who else will support you during labor and postpartum? Doula Services Requested What services are you interested in? Birth Doula Support Postpartum Doula Support Virtual Support Prenatal Education Breastfeeding Support Newborn Care Education Labor Preparation Emotional Support Bereavement / Loss Support High-Risk Pregnancy Support Any other services? Birth Preferences Preferred Birth Type Vaginal Birth Natural Birth Epidural C-Section Undecided Pain Management Preferences Vaginal Birth Natural coping techniques Epidural IV medication Open to options Would you like support with: Breathing techniques Labor positions Birth planning Advocacy support Comfort measures Partner coaching Postpartum Needs Are you interested in postpartum support? Yes No Type of support needed Overnight care Daytime care Breastfeeding support Newborn care Emotional support Meal preparation Household support Sibling support How many hours per week do you anticipate needing support? Mental Health & Emotional Wellness How are you currently feeling emotionally? Calm Anxious Overwhelmed Excited Sad Unsure Have you ever experienced: Postpartum Depression Anxiety Pregnancy Loss Fertility Challenges Birth Trauma None Lifestyle & Home Environment Do you have pets in the home? Yes No Do you smoke in the home? Yes No Do you have reliable transportation to appointments? Yes No Do you feel safe in your home environment? Yes No Payment & Insurance How will services be paid? Self-pay Insurance Medicaid Payment Plan Are you using any of the following programs? Medicaid WIC Community Program None Scheduling Preferences Preferred days for support Monday Tuesday Wednesday Thursday Friday Saturday Sunday Preferred time Morning Afternoon Evening Overnight How Did You Hear About Mother of Life Doula? Google Social Media Referral Hospital Community Organization Event Consent & Acknowledgment I understand that Mother of Life Doula provides non-medical support services and does not replace medical care from licensed healthcare providers. I consent to receive services and allow the collection of information necessary to provide safe and supportive care. By typing my name, I understand that I am signing this document electronically(required) Todays Date (YYYY-MM-DD)(required) ← Back Next → Submit Δ
