Doula Client
Intake Form



Thank you for taking the time to complete the following form.  By doing this, I am able to get to know you and your needs so that I may help you to the best of my ability.  Everything you share with me remains confidential, as I am the only one who sees the submitted information.

Thank you, again, and I look forward to being a part of this journey with you.

Mother's Name *
Mother's Name
Personal Information
Do you currently or have ever had any of the following
Psychological History
You are by no means obligated to answer these questions. Everything you share and we discuss is confidential.
How do you feel this pregnancy has been? How are your eating habits and exercise routines? Are you currently on any medication?
Would you consider have a doula in training shadow me at your birth?
There are new doulas in my network that are looking for experience. This will be at no extra fee. She will be my shadow and will meet the couple with me before the birth. You are not obligated to do this and it absolutely up to the birthing parents.