Client Intake - Atala Doula Services

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 in-person meetings take place unless you specify other arrangements or opt for virtual meetings.

Name of partner(s)/additional support people & relation (if applicable)

Relation examples: spouse, husband, wife, fiancé/fiancée, boyfriend/girlfriend, domestic partner, co-parent, your parent, sibling, friend, etc.

Partner(s)/additional support people phone number(s) (if applicable)

Partner(s)/additional support people preferred pronouns (if applicable)

Preferred term(s) for your relation(s) 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) your family wishes to have used.

Emergency contact name(s) and number(s)

Please provide the name and number for at least one person your doula can contact in the event of an emergency/crisis regarding your physical or mental health. If you include multiple contacts, please specify the order in which they should be contacted and any other details you want your doula to know.

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 is your planned birthing location?

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

Date you will be 40 weeks pregnant (estimated due date/EDD) or baby's date of birth if already born?

What number pregnancy/baby is this for you?

Please include live births, miscarriages, abortions, and stillbirths.

Any complications/concerns for this pregnancy/birth?

Previous births/deliveries

Please check all that apply.

Location/attendants for previous births/deliveries

Please check all that apply.

Any complications/concerns with previous pregnancies/births?

Any physical or medical conditions that you think may impact your birth or postpartum experience?

How are you planning to feed your baby?

If you are planning to bodyfeed or pump milk for bottle feeding, did you notice expected breast/chest changes during puberty and early pregnancy?

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

Please check all that apply.

Do you or anyone who lives in your home smoke tobacco products?

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?

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

Do you feel comfortable with being touched (massage, holding your hand, gentle strokes on arms/legs, rubbing your feet, etc.)?

Is there any area of your life in which you feel unsafe or need support?

I need help with food.
I need help with my mental health.
I need help with a place to live.
I feel unsafe at home or work and need help.
Yes, please contact me about this question so I can tell you more.
I currently feel safe and supported in all areas of life, but thank you for asking.

Please check all that apply.

Would you be comfortable with me asking questions or providing questionnaires for trauma screening?

During labor/birth and postpartum, emotions associated with prior trauma can come to the surface. As your doula, it may be helpful for me to be aware of this history and what your triggers are or may be.

Are you comfortable receiving foods, teas, and/or baked goods made in my home?

If yes, any food allergies or other dietary restrictions/requirements that I should be aware of?

Any scent, latex, or other allergies or aversions?

So that I can be sensitive to your needs, any personal, cultural, or religious beliefs/traditions that I should be aware of?

What helps you manage stress in your life? What helps you feel calm and grounded?

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?