DOULA CLIENT INTAKE FORM Template from cradledapp.com/guides/doula-intake-form-template Edit the questions to fit your practice. Ask only for what you need to support your client, keep the answers private and secure, and make it clear which questions are optional. Laws about collecting and storing health information vary by location, so check the rules where you practice. Replace everything in [BRACKETS]. Delete any section that doesn't apply. ------------------------------ A NOTE FOR YOUR CLIENT Thank you for choosing [Business name]. These questions help me understand you, your pregnancy, and the support you want, so our first visit can focus on what matters most to you. Answer only what you're comfortable sharing. Anything marked (optional) can be skipped, and we can talk about any of it in person instead. Your answers stay private between us. ------------------------------ 1. ABOUT YOU Full name: Name you'd like me to use: Pronouns (optional): Date of birth: Phone: Email: Home address: Best way to reach you: [ ] Call [ ] Text [ ] Email Preferred language: Partner or main support person Name: Pronouns (optional): Relationship to you: Phone: Email: Will they be at the birth? [ ] Yes [ ] No [ ] Not sure yet Emergency contact (if different) Name: Relationship: Phone: 2. YOUR PREGNANCY Estimated due date: Is this your first baby? [ ] Yes [ ] No If not, how many children do you have, and how old are they? Are you expecting more than one baby? [ ] Yes [ ] No Care provider: [ ] OB [ ] Midwife [ ] Family doctor [ ] Other: ______ Care provider's name and practice: Planned place of birth: [ ] Hospital [ ] Birth center [ ] Home Name of hospital or birth center: How has your pregnancy been so far? 3. HEALTH INFORMATION (OPTIONAL) I'm not a medical provider, and I don't need your full medical history. If there's anything about your health you'd like me to know so I can support you well, you can share it here, or we can talk about it in person. Is there anything about your health or this pregnancy you'd like me to be aware of? Do you have any allergies (including to foods, oils, or scents)? Is there anything that's been flagged by your care provider that you'd like support with? 4. PREVIOUS BIRTHS (IF ANY) How did your previous birth or births go? Is there anything from a previous birth you'd like to do differently this time? Is there anything from a previous birth you'd like me to know, or that you'd like to talk through? (optional) 5. HOPES AND CONCERNS Why did you decide to work with a doula? What are you most looking forward to? What are you most worried or unsure about? In three words, how would you like to feel during your birth? Have you taken, or do you plan to take, a childbirth class? [ ] Yes [ ] No [ ] Planning to Which topics would you like to learn more about before the birth? [ ] Stages of labor [ ] Comfort measures [ ] Pain medication options [ ] Interventions [ ] Cesarean birth [ ] Your rights and informed consent [ ] Feeding [ ] Newborn care [ ] Postpartum recovery [ ] Partner's role [ ] Other: ______ 6. HOW YOU LIKE TO BE SUPPORTED When you're stressed or in pain, what usually helps? How do you feel about touch, such as massage or counter-pressure? [ ] Welcome [ ] Sometimes, ask first [ ] Prefer not Are there things you'd prefer I avoid (words, scents, music, kinds of touch)? Are there cultural, religious, or family traditions you'd like honored during the birth or after? Is there anything that would help you feel safe and respected with your care team? How involved would you like your partner or support person to be? 7. AFTER THE BIRTH How are you planning to feed your baby? [ ] Breast/chest [ ] Formula [ ] Both [ ] Not sure yet Who will be helping at home in the first few weeks? Are there other children or pets at home? Is there anything you're worried about for the postpartum period? Have you experienced anxiety or depression, during pregnancy or before? (optional) This helps me know how to support you and when to suggest extra resources. 8. LOGISTICS How did you hear about me? Is there anything that might make it hard to reach you or get to the birth (parking, building access, a long drive)? Is there anything else you'd like me to know? ------------------------------ POSTPARTUM DOULA SECTION (optional, for postpartum services) Baby's name and date of birth (or due date): How was the birth? How are you feeling, physically and emotionally? How is feeding going? How is everyone sleeping? What would help you most right now? [ ] Rest and overnight support [ ] Feeding support [ ] Newborn care [ ] Help with siblings [ ] Light household help [ ] Meals [ ] Emotional support [ ] Other: ______ Which days and times would you like support? Is there anything about your home I should know before I arrive (pets, parking, shoes off, quiet hours)? ------------------------------ CONSENT I understand that my doula provides non-medical support and that my answers are used only to support me. I can update or withdraw anything I've shared at any time. Name: ______________________________ Date: ____________