BIRTH + POSTPARTUM CLIENT FORM — The Lovely Mother

birth + POSTPARTUM bundle client intake form

fill out the form below

This form is for clients who will be using my BIRTH AND POSTPARTUM BUNDLE doula services only.

If you are looking for birth client form OR postpartum client forms, please click below:

postpartum CLIENT FORM

birth client form

(Psst… This form is for established clients. If you’re looking to contact me, click below:)

Contact me

Pregnant Person's Name

First Name

Last Name

Pregnant Person's Email

Pregnant Person's Phone

(###)

###

####

Partner/Support Person's Name

First Name

Last Name

Partner/Support Person's Email

Partner/Support Person's Phone

(###)

###

####

Please list names of any additional support persons who will be present for birth and/or postpartum:

(Please list name + relation)

Emergency Contact

Name/Relationship/Contact

Estimated Due Date

YYYY

Care Provider

Birthing Location

Have you taken a tour of your birthing location?

Yes

I'm planning to

Pregnant Person's Allergies

(Food/Medication)

What number pregnancy is this for you?

Number of previous births:

Please list number of living children and their ages:

Have you taken a childbirth education class? (Please list date/location)

Do you plan to breastfeed?

Keeping in mind always, fed is best :)

Have you made a birth plan?

(If not, we can do this together)

Are there any preexisting medical or other conditions you'd like me to be aware of?

Please list any conditions developed during pregnancy that may affect your birth or postpartum experience:

Please describe your physical and emotional prenatal/pregnancy experience so far:

What is your birth vision? If everything went perfectly according to this vision, describe what this looks/feels like for you:

Are there any comfort measures you've used in the past that you found especially helpful?

Please list any comfort measures you would NOT like to use:

(i.e. massage, aromatherapy, etc)

What fears or concerns have come up for you regarding your birth?

What do you think will be your greatest strength for your labor and birth experience?

What comes to mind when you think of comfort and/or feeling safe?

This can be a memory, a type of music, a person, anything!

What fears or concerns do you have about being a new parent? Or anything related to the postpartum period?

What do you think will be your greatest strength during the postpartum period?

Will you be taking maternity leave? When do you plan to return to work?

Do you have anyone planning to come play a supportive role after baby arrives?

Please list name, relation, and time frame they plan to help

How would you say you typically react to/handle stressful or intense situations?

Is there anything you like to do to de-stress?

What are you most looking forward to about giving birth and postpartum?

In what ways are you hoping a doula's support will be helpful to you?

Is there anything about your partner/support person you'd like me to know?

I.e. their personality traits, questions, fears, etc.

Please share anything else you'd like me to know about you, your family, or any other topics you'd like to discuss: