Postpartum Doula Support Intake Form

Full Name: *

Email: *

Partner/Support Person’s Name (if applicable): *

Emergency Contacts (Name & Phone Number): *

Phone Number: *

Home Address: *

Estimated Due Date: *

Baby’s Name (if known): *

How Many Weeks Pregnant: *

Planned Birth Location: *

Healthcare Provider’s Name & Practice: *

Any complications during labor or delivery we should know about? *

Number of children at home (including newborn): *

Ages of other children (if any):

Any pets at home?

Languages spoken at home: *

Do you have a support system nearby (family, friends, etc.)? *

Is this your first pregnancy? *

Yes

No

If no, how many previous pregnancies?

How many live births?

Any previous pregnancy complications?

Have you experienced any pregnancy complications this time? If yes, please explain: *

Do you have any medical conditions that may affect your pregnancy or birth?

*

Are you currently taking any medications or supplements? If yes, please list: *

Do you have a birth plan?

Yes

No

What type of birth are you planning? *

What are your top priorities for your birth experience?

*

Do you have any specific concerns or fears about labor and birth?

*

Any cultural or religious preferences regarding birth or postpartum care?

*

Which areas of support are most important to you? (Check all that apply) *

How do you plan to feed your baby? *

Breastfeeding

Formula feeding

Combo feeding

Not sure yet

How are you feeling emotionally since birth (or during late pregnancy)? *

Have you ever experienced depression, anxiety, or trauma (including birth trauma)? *

Ideal start date for doula support: *

Preferred days/times for support: *

Any dates/times that do not work: *

Preferred number of visits per week: *

Additional Notes or Questions
(Anything else you’d like us to know or ask about?) *