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Mother of Life Doula
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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
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Todays Date
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YYYY-MM-DD
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