Client Intake

All birth and postpartum doula clients should complete the following form. This will provide the information necessary to start working effectively with your doula.

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Name *

First

Last

Preferred pronouns

Email *

Phone number *

Please provide the best number to reach you.

Home address *

This will be where most of our meetings take place unless you specify other arrangements.

Name of partner (if applicable)

Partner's phone number (if applicable)

Partner's preferred pronouns (if applicable)

Preferred term(s) for your relation to baby? (mom, mother, mommy, mama, dad, father, daddy, papa, birth giver, gestational parent, etc.)

This is completely up to you and not limited to the terms suggested. Please feel free to share whatever term(s) you/your partner wish to have used.

How do you believe having a doula will benefit you? *

Have you participated in any childbirth classes, or do you plan to? *

• Yes
• No

If yes, please provide details (class name, dates, etc.). This will allow me to tailor the information you may benefit from during our time together.

For birth doula clients, where do you plan to deliver?

Please provide the name of the hospital or birthing center, or write “home” if planning a homebirth.

What number pregnancy/baby is this for you? *

Previous births/deliveries

• Vaginal
• Cesarean
• VBAC
• Miscarriage (<20 weeks)
• Stillbirth (>20 weeks)
• Abortion

Please check all that apply.

Location/attendants for previous births/deliveries

• Home
• Hospital
• Independent birthing center
• Doctor
• Midwife
• Doula
• Unassisted

Please check all that apply.

Any complications/concerns with previous pregnancies/births?

Any complications/concerns for this pregnancy/birth?

How are you planning to feed your baby? *Exclusively bodyfeed (directly from breast/chest)Exclusively pump and bottle feedExclusively bottle feed with donor human milkExclusively bottle feed with formulaShared lactationOtherCombination of any of the aboveUndecided

If you are planning to bodyfeed or pump milk for bottle feeding, did you notice expected breast/chest changes during puberty and early pregnancy?Yes, I noticed changes during both puberty and pregnancy.I noticed changes only during puberty.I noticed changes only during pregnancy.No, I have not noticed any changes.

For postpartum doula clients, are there any areas of support you feel are most needed?

• Emotional support
• Birthing person care (hydration, comfort, rest)
• Newborn care (diaper changes, bathing, bedtime, feeding, routines)
• Lactation/feeding support
• Bottle preparation/feeding
• Baby soothing/bonding
• Integration of newborn into family (siblings, pets, extended family)
• Light meal/snack preparation
• Light housekeeping/organization
• Parenting relief to nap, shower, or eat
• Assistance with errands
• Companion for appointments
• Other – to be discussed

Please check all that apply.

Do you or anyone who lives in your home smoke tobacco products? *NoYes, inside and outsideYes, outside onlyYes, inside onlyPrefer to discuss later

If only using other forms of consumption (e.g., dip, snuff etc.), answer No.

Do you or anyone who lives in your home smoke cannabis products? *NoYes, inside and outsideYes, outside onlyYes, inside onlyPrefer to discuss later

If only using other forms of consumption (e.g., edibles, tinctures, etc.), answer No.

Would you be comfortable with me asking questions or providing questionnaires for trauma screening? *Yes to anyYes only to verbal questionsYes only to written questionnairesNoPrefer to discuss later

If you have any plans or goals you want to achieve for your labor/birth, regarding infant feeding or diapering, or any others, please share them here.

Favorite color?

Interested in receiving information about upcoming events and other products/services offered by Atala Doula Services? *

• Yes
• No

Questions? Requests? Any other information you wish to share?

Submit