birth client intake form — The Birth Partner

Email

Partner/ Support Person's Name

Estimated Due Date

Emergency Contact

(Name/Relationship/Phone Number)

Care Provider

Birthing Location

Pregnant Person Allergies?

(Food/Medication)

Please list any medical conditions prior to conception that would impact pregnancy or birth.

Other:

How much, and how well are you sleeping during this pregnancy?

What number pregnancy is this for you?

Number of previous births:

Please list the number of living children and their ages

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

Have you taken a childbirth education class? Please list date and location.

Do you plan to take any additional childbirth/newborn education classes? Please list date and location.

Other

Are you and/or your partner/support person reading and books on pregnancy/childbirth/postpartum or breastfeeding. Please list below.

Do you have a postpartum support plan?

What is your birth vision? If things go 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)

Have you shared your birth plan/preferences with your medical provider?

During early labor, when does your medical provider want you to call them?

Have you discussed protocols with your care provider if you go past your estimated due date?

Please describe any activities you have been going to physically/emotionally prepare for your birth. (ex. medication, exercise, etc.)

Have you packed a birth bag? (if no, we can do this together.)

What do you think will be your greatest challenge for this pregnancy/birth/postpartum experience?

Do you have any persistent concern/fears regarding your birth?

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

In previously painful or emotionally intense situations (illness, injury, surgery) what have you found comforting?

Please list any other techniques you would like to try:

Other

Other:

In what ways do you hope a doula's support with be helpful to you? What types of assistance do you imagine will be most useful?

Other:

How does your partner/support person want to be involved in your birth? I.e. Hands ons, share support with doula, or let the doula take the lead.

Please share anything else you would like me to know about you or any topics you would like to discuss.

Client Intake Form