Intake form

Thank you so much for choosing me as your doula!
Please complete the form below prior to our first prenatal session.

(Please do not use the ENTER key as this will submit the form. Thank you!)

Your name

First Name

Last Name

Estimated due date

Home address

Phone number

Partner's name (if applicable)

First Name

Last Name

Partner's phone number

Partner's email

Your chosen place of birth

(ie. Byron Hospital Birth Centre, Lismore Base Hospital, Home)

Is this your first pregnancy? If not, please describe prior pregnancy/birthing experiences. What was good? What was not so good?

What do you find challenging at the moment or currently struggle with in your life (in general or in regards to your pregnancy)?

What kind of support are you hoping to receive from me?

Have you had any life trauma that may impact on your birth experience?

How do you counteract stress, overwhelm and pain? How do you usually deal with this? What calms you down/ makes you feel better/ relaxes you?

Who will be present at this birth and what do you expect their roles to be?

If applicable, how would you like me to support your partner during pregnancy and after birth?

(ie. any areas of concern you have; any areas of support you are foreseeing)

Please describe your ideal birth. How do you envision it? Please be specific.

Please describe any concerns or fears you have around labour, birth, postpartum or parenthood.

If you've breastfed before, please describe previous breastfeeding experiences

If applicable, please describe previous postpartum experiences: What was good? What was not so good?

Any medications or added information you would like to share with me? Or anything I need to know about your health? Is there a history of mental health conditions in your family or have you ever experienced a mental health condition yourself?

(ie. any physical injuries; anxiety, PTSD, panic disorder, depression, eating disorders, etc.)

Who will support you after birth? Do you have friends and family around for support or are you planning to hire help?

On a scale from 1 to 10 how hard do you find it to ask for and accept help from others?

1: "I find it easy to ask others for help and support when I really need it." <---> 10: "I'm used to doing everything myself and find it hard to ask for help."