Birth Doula Services Intake Form

Name *
Phone *
Please enter the best number to reach you at
Estimated Due Date *
Estimated Due Date
Other Support Person's Name
Other Support Person's Name
Support Person's Phone
Support Person's Phone
Midwife or Doctor's Name *
Midwife or Doctor's Name
Midwife/Doctor's Phone Number *
Midwife/Doctor's Phone Number
Birth Place Address *
Birth Place Address
Home address for home birth
Any specific newborn procedure requests? *
I prefer the following breathing techniques: *
I like the following relaxation techniques: *
Do you like your eyes open or closed during relaxation? *
Do you respond better to sound or silence for relaxation? *
Do you have a favourite CD or playlist you would like to listen to during labour? *
What kind of massage pressure best relaxes you? *
What depth of pressure do you like most? *
Would you like any hydrotherapy during labour? *
What is your preferred delivery position? *
Do I need to call anyone to care for pets or other children? Do you have any allergies? Anything else?