BIRTH CLIENT FORM — The Lovely Mother

birth client intake form

fill out the form below

This form is for clients who will be using my LABOR/BIRTH DOULA services only.

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

Birth + POSTPARTUM bundle client form

postpartum client form

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

Contact me

The following form is an intake questionnaire to dive a little deeper into your personality and preferences. The information shared is used solely to help me better serve you and will not be shared with anyone else. You may omit any information you don’t wish to share with me. If we’re working on a birth plan together, a separate form will be sent to you.

Please reach out with any specific questions!

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

Support Person's Name

(If Applicable)

First Name

Last Name

Partner/Support Person's Email

Partner/Support Person's Phone

(###)

###

####

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)

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:

Have you made a birth plan?

(If not, we can do this together)

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

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

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

(I.e. music, exercise, meditation, anything!)

What do you think will be your greatest strength for your pregnancy/birth/postpartum 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!

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

(This can be for any situation and not just a previous birth)

Are there any comfort measures you've learned of that you'd like to try?

Do you enjoy physical touch as a comfort measure?

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

(i.e. massage, aromatherapy, etc)

Are you planning to breastfeed?

(Totally okay if you don't know yet!)

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

Is there anything specific you'd like to discuss or learn about during our prenatal visits?

Is there anything specific to 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: