Register forDoula Services
Name & Age
Description of previous birth(s). Please include what you liked/disliked, time elements, medical procedures, and partner involvement etc.
Home Phone
Mom's Email Address
Partner's Name & Age
Mom's Cell Number
Partner's Cell
Partner's Email Address
Due Date
Care Provider and Planned Birth Location
Referred to doula services by
List any complications experienced during previous pregnancies or your current pregnancy
List any classes you have taken/plan to take during this pregnancy
Occupation/Employer
Partner's Occupation/Employer
Books you and partner have read to prepare for your upcoming birth
Mom: What are your goals for this birth experience besides health of mom & baby?
Why are you interested in doula services? (Please provide an answer from both mom & partner)
Partner: What are your goals for this birth experience ?
Have you discussed your birth goals and options with your care provider?
Have you written, or do you plan to write a birth plan?
Do you plan on having any family or friends present for your labor/birth? If yes how do they feel about your birth plans?
Is there anyone you would not want to be present? If yes how will this be handled?
Mom: What concerns you most about this labor/birth other than the health of mom & baby?
Dad: What concerns you most about this labor/birth other than the health of mom & baby?
What else should your doula know about you to assist you during this experience?
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