To become a doula client: step 1 - complete this form and use submit button to send. step 2 - use PAY NOW button at bottom of page to submit your non-refundable $400 deposit step 3 - balance is due at 35 week doula visit

Mom's Name

First Name

Last Name

Mom's Age

Mom's email:

Mom's Phone

(###)

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Mom's Occupation/Employer

Partner's Name

Partner's Age

Partner's email:

Partner's Phone:

(###)

###

####

Partner's Occupation/Employer

Street Address

City

Zip code

Referred to Birth Help by:

Baby's Due Date

YYYY

Doctor/Midwife's Name

First Name

Last Name

Location of birth

Baby #

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 state why you would like doula support.

Have you experienced any of the following?

Previous pregnancy

Unplanned pregnancy

Complications with previous pregnancy

Miscarriage

Abortion

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, beside a healthy mom and baby?

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

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

If others will be present at your labor/birth, 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 your labor and birth, excluding health of mom and baby?

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

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

To become a doula client: 1. complete this form and use submit button to send 2. use PAY NOW button to submit your non-refundable $400 deposit step 3 - balance is due at 35 week doula visit

Form - Become Client

Birth Help