Doula Intake Questionnaire Date MM DD YYYY Birthing Person's Name * First Name Last Name Personal pronouns Occupation Contact Number (###) ### #### Email address Partner/Support Peron's Name First Name Last Name Personal pronouns Occupation Phone Number Email address Home Address How would you like us to access your home Is there a specific code? Specific door to enter? If we are to arrive while you are in labour, are you ok if we let ourselves in? EDD Doctor/Midwife name Do you currently have children? If so, what are their names? Ages? What are the sleeping arrangements in your home? Is there anything you would like us to know about your previous pregnancies? Do you have any current health concerns? Do you have allergies/does anyone in your house have known allergies? Do you have pets? Type(s)? Name(s)? Does anyone smoke in your home? Other practitioners offering support Caffeine/alcohol/tobacco/drug use Reason for wanting a doula What does your support system look like Greatest fear Feeding plans Is there anything else you would like us to know? For Birth Clients Only Who will be present at the birth Would you like pictures or videos taken at your birth? Who will be cutting the cord Is there anything specific about your birth plan you would like us to know at this time Thank you!
