New Client Intake Form

Getting to know you, getting to know all about yoooou…

Please take your time with these questions and answer to the best of your ability. It’s okay if you’re unsure about some, or if you change your mind later!

PRIVACY POLICY
Your personal information will be kept private and will never be shared with anyone. The information in these questions is intended to help me support you. It is your responsibility to share any and all relevant medical information with your healthcare provider(s). As a Postpartum Doula, I do not offer medical advice. For any concerns or issues that are out of my scope of practice, I will do my best to suggest referrals or recommend that you seek the help of a qualified medical professional.

Your Name(required)

Address

Phone number(required)

Email(required)

Preferred contact method (text / phone / email)

Partner's name (if applicable)

Partner's phone

Partner's email

Due date / Baby's birth date(required)

Intended place of birth

Midwife / Doctor's name

Midwife / Doctor's phone

Please list the names and ages of other children living in your home.

Please list any pets (number, size, breed).

Does anyone smoke in your home?

Does anyone in your home have food allergies or a special diet I should be aware of? Are any foods “off limits” in your home?

Do you and/or your Partner intended to take time off work? If so, how long?

Please list any other sources of support you expect to have in the postpartum period (e.g. relatives, meal train, etc.).

How do you plan to feed your baby?

Are there any parenting techniques you plan to use or have questions about?

Do you have any medical concerns you feel I should know about?

Do you have a history of postpartum mood disorders or mental health concerns?

Do you have any fears about birth, parenting, or the postpartum period?

Do you have any concerns that are specific to your Partner/partnership, or single-parenting?

What are your primary goals in having a Postpartum Doula?(required)

What do you anticipate needing the most help with during the postpartum period?(required)

What are some of the little things that bring you JOY? What are your primary love languages?

Anything else you would like to add?