To become a doula client: Step 1 - complete this form and use submit button to send. Step 2 - use Zelle (doula@birthhelp.com) or Paypal button at bottom of page to submit your $400 non-refundable deposit Step 3 - balance is due at 35 week doula visit

Mom's Name

First Name

Last Name

Age

Email Address

Mom's Phone

Mom's Occupation/Employer

Street Address

City/State

Zip Code

Partner's Name

Age

Partner's email

Partner's Phone

Partner's Occupation/Employer

Referred to Birth Help by

Baby's Due Date

OB/Midwife's Name

Location of Birth

Baby #

Primary Doula

I'm requestion for primary doula

Provide a narrative description of previous births, including time elements, events, medical procedures, what you liked and disliked, and partner's involvement, etc.

Mom: Briefly state why you would like doula support.

Partner: Briefly describe why you would like doula support.

Have you experienced any of the following?

Previous pregnancy

Unplanned pregnancy

Miscarriage

Abortion

Complications with previous pregnancy

If you selected any options for the previous question, provide the date.

List any complications experienced during this pregnancy.

Describe any prenatal testing, the reason, and the results for this pregnancy.

List prenatal classes taken/planned for this pregnancy.

Mom: List any pregnancy-related books read during this pregnancy.

Partner: List any pregnancy-related books read during this pregnancy.

Mom: What are your goals for labor and birth, in addition to a healthy mom and baby?

Partner: What are your goals for labor and birth, in addition to a healthy mom and baby?

Have you discussed your birth goals and/or birth options with your OB/Midwife?

Do you anticipate any family members or friends to be with you during your labor and birth?

If others will be present, how do they feel about your birth goals and plans?

Mom: What concerns you most about your labor and birth, excluding health of mom and baby?

Partner: What concerns you most about this labor and birth, excluding health of mom and baby?

Mom: What would you like your doula to know about you?

Is there anything else you would like your doula to know about your past, your present, or your wishes for the future that will help her provide you with better care?

Partner: What would you like your doula to know about you?

To become a doula client: Step 1 - COMPLETE THIS FORM AND USE 'SUBMIT' BUTTON Step 2 - use Zelle (doula@birthhelp.com) or Paypal button at bottom of page to submit your $400 non-refundable deposit Step 3 - balance is due at 36 week doula visit

USE ZELLE (doula@birthhelp.com) or Paypal to place your $400 non-refundable deposit.

Form - Become Client

USE ZELLE (doula@birthhelp.com) or Paypal to place your $400 non-refundable deposit.

Birth Help