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 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.

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 birthing 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? *

Any complications/concerns for this pregnancy/birth?

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?

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.

Do you feel comfortable with being touched (massage, holding your hand, gentle strokes on arms/legs, rubbing your feet, etc.)?Yes! I'm a very physically affectionate person and don't mind being touched by others.It depends on the mood and circumstances and who is giving the physical affection.I am usually a touch-me-not, but I could see that changing during labor/birth/postpartum.I absolutely do not like being touched. Please refrain from touching me without explicit consent.

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? *Yes to anyYes only to verbal questionsYes only to written questionnairesNoPrefer to discuss later

Are you comfortable receiving foods, teas, and/or baked goods made in my home?Yes, please!No, thank you.Please discuss with me first.

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

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

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