Client Resources Mother’s Name(required) Partner’s Name (required) Mother’s Email(required) Partner’s Email(required) Mother’s Phone Number(required) Partner’s Phone Number(required) Home Address(required) Estimated Due Date (EDD)(required) Provider’s Name(required) Birth Location(required) Have you had any previous pregnancies? If so, how many? If applicable, please share about previous birth experiences. Have you had any previous C-sections? If so, how many? Have you had any previous or current pregnancy complications? If so, please explain. Do you have any medical conditions? If so, please explain. Do you have any allergies? If so, please explain. Do you have or have you had any injuries? If so, please explain. Who will your support people be during labor? Is there anything specific that your support people should or should not do? Do you have any fears or reservations about anything regarding your birth experience? Is there anything specific that you need help advocating about? What does your ideal birth experience look like? Have you taken any childbirth education, breastfeeding, or parenting classes? If so, which ones? Do you plan to breastfeed? If so, do you have any questions about it? Would you like doula support at your home in early labor? What support are you looking for in a doula? Do you have any other comments or questions? Thank you for your time! I look forward to working with you! ← Back Next → Submit Δ