CLIENT INTAKE FORM

Hi there,

Thanks for choosing me as your Doula. I’m so excited to support you and be a part of this beautiful journey through pregnancy, birth and in the early postpartum. So that I can best be of service, it would be great to hear about you, your partner, your wishes for your birth and any expectations you have of me.

Please get in touch if you have any concerns.

Many thanks,

Amanda

Your name

First Name

Last Name

Do you have any other names?

(eg a nick name or maiden name)

First Name

Last Name

Your phone number

Your email

Your job title and a brief description of the work you do

Partner's name

First Name

Last Name

Your partner's phone number

Your partner's email

Your partner's job title and a brief description of the work they do

Your home address

Please include your current home address, and if you are moving, your new address too.

Your estimated due date (EDD)

How was your EDD calculated?

(eg IVF, LMP or early ultrasound dating scan)

Where are you planning to birth your baby?

Are you a public or private patient?

If public, which program are you part of?

(eg MGP, GP shared care, high risk, homebirth...)

If private, who is your provider (and who is their back up)?

(eg Obstetrician or Midwife)

Is this your first baby?

If no, how many other pregnancies/children have you had?

If you have other children or previous pregnancies, please tell me about your previous birth experiences

Do you know your the gender of your baby?

How are you planning to feed your baby?

(eg breast, expressed, formula, mixed, donour, unsure...)

Tell me about the kind of birth you'd like to have with this baby (or babies?)...

Do you have other support networks? If so, please tell me about them

(eg very close family, psychologist, house cleaner, etc...)

What inspired you to seek the assistance of a Doula?

What are your (and your partner's) expectations of me as your Doula?

Have you completed, or are you planning to undertake any childbirth education classes? And where/when did/do you plan to take them?

(eg hypnobirthing, she births, calm birth, hospital classes, breastfeeding, infant first aid or newborn care classes...)

Is there anyone else you would like me to have contact details for, or that you plan to have attend your birth?

(eg your mum, sister, friend etc...)

Do you have any complications with this pregnancy, or other medical conditions I should know about?

Is there anything else you want to share with me or feel I need to know?

Birth doula clients enjoying a special moment upon meeting their healthy baby boy at Royal Hospital For Women in Randwick, Sydney, Australia.

“Amanda was such a warm, calming and supportive presence for the birth of our son, and by our side for more than 24 hours of labour! We knew we would hire her after meeting her for the first time - and my husband was immediately convinced on the benefits of hiring a doula, having been previously sceptical. Her service was comprehensive, and we learned so much about the labour and birth process from her - particularly that you can say no to anything you don’t understand or feel comfortable with. We we ended up with the best outcome possible and would highly recommended Amanda as a beautiful support for labour and birth. Thanks Amanda!! Xx”

— ALISON & PARTNER: BIRTH DOULA PACKAGE CLIENTS

See more testimonials here.