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Meet the Team
Midwifery
Midwifery FAQs
Request a Midwifery Consult
Lactation Services
Lactation Client Intake Form
Craniosacral Therapy/Myofascial Unwinding
Adult Craniosacral Therapy/Myofascial Unwinding Client Intake Form
Pediatric Craniosacral Therapy/Myofascial Unwinding Client Intake Form
Doula Services
Birth Planning
Doula Client Intake
Doula FAQs
Doula / Labor Support Packages
Doula Gift Certificates
Placenta Encapsulation
FAQs about Placenta Encapsulation
Placenta Benefits
Placenta Encapsulation Resources
Registration for Placenta Encapsulation
Placenta Encapsulation Gift Certificates
Testimonials
Blog
& More…
Childbirth Classes
The Storks Complete Childbirth Course
TGS Childbirth Course FAQS
Registration for TGS Childbirth Course
Childbirth Education Gift Certificates
Childbirth Course Evaluation
Spinning Babies® Parent Class
Spinning Babies Registration
Doula Workshops
Registration for Doula Workshops
Doula Training Gift Certificates
Client Intake Form 2
GreenStork2016
2017-12-22T20:56:47+00:00
Doula Client Intake – Part 2
New Client Form
Step 1 of 2
What is your Guess date (estmated due date)?
*
Where are you planning to give birth?
*
Home
Hospital
Birth Center
Undecided
What is your midwifes or OB's name?
*
Mother's First Name
*
Mother's Last Name
*
Mothers Birthdate
*
Address
*
Address Line 2
City
*
State
*
Zip Code
*
Mothers Phone
*
E-mail
*
Mothers Occupation
Still working?
Yes
No
Will you return to work after the baby is born? If so when?
Partner's Name
E-mail
Phone
Will your partner take time off work after the baby is born? If so, how long?
Have you taken any childbirth ed courses?
Was your current pregnancy planned or unplanned?
Planned
Unplanned
How were you feeling emotionally when you found out you were pregnant?
How are you feeling emotionally now?
Who are your support people (partner, friends, family etc.)? Explain.
Do you know the sex of your baby? Do you plan to find out?
How has your pregnancy been physically?
Have you had any complications?
How do you plan to birth your baby (vaginal, c-section, use of medications, environment/surroundings, birthing methods, etc.)?
Who do you plan to have with you while you are birthing your baby?
Why did you decide to contact a doula?
What role does your partner plan on taking during the birth? What role do others plan on taking (if you will have other support people present)?
Do you want your partner to be primary, secondary, or equal support with the doula? Please explain.
List any fears/anxieties you have surrounding this pregnancy, labor and delivery, life with baby? Please number these on a scale of 1-10 (1 being minimally fearful, 10 being unnaturally or extremely fearful).
Have your partner list fears/anxieties here, rating them as you did above.
Have you had any surgeries or procedures on your uterus or cervix? Explain.
Did you utilize any infertility treatments (natural or medical) to help conceive this baby? Please list.
Do you plan on breastfeeding?
*
Yes
No
Undecided
Please circle any of the following categories that you would like to discuss during our visits
*
Baby Care
Birth Plan
Breastfeeding
Breathing/Relaxation
Cesarean Birth
Circumcision/RIC
Immunizations
Comfort Measures (non-drug)
Communication with Care Provider
Emotional Recovery
Epidural/Pain Medications
Episiotomy
Fear
Infant Bonding
Nutrition/Exercise
Partner Support
Physical Recovery
Placenta Encapsulation/Preserving
Positions for Labor
Role of the Doula
Evidence Based Resources
Delayed Cord Clamping
Magic Hour
Routine Hospital Procedures
Epidural/Pitocin Spiral
Oxytocin
Newborn Stomach Size
Squats
Pregnancy exercises to prepare for labor
Anything else you would like to discuss:
Previous Pregnancies (Step 2)
Your other children (names and ages):
How many previous births have you had?
Miscarriages?
Did you have any complications in previous pregnancies? If yes, please explain.
Number of vaginal births?
Number of cesarean births?
Full term or preterm?
List each babies birth weights
Did you experience complications in any of your labors?
Did any of your babies need special care after birth?
Did you breastfeed? How long?
Did you experience postpartum depression? Explain
What supports do have in place this time to help with possible postpartum depression?
Have you processed your previous birth stories?
Yes
No
Would you say you accept your previous birth stories? If no, please explain.
Submit
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