Birthing Person's Name
*
First Name
Last Name
Pronouns
Date of Birth
MM
DD
YYYY
Birthing Person's Phone Number
(###)
###
####
Email
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
If you have a primary birth partner, please tell us about your relationship:
Birth Partner
First Name
Last Name
Pronouns
Birth Partner's Phone Number
(###)
###
####
Estimated Due Date
MM
DD
YYYY
Who is your current care provider?
Intended Birthing Location
Have you experienced any complications or unusual things with your current pregnancy?
How can we support your religious, spiritual, or cultural needs during birth?
While we always strive to practice in a trauma-informed way, it helps us to serve you best when we know a little of your history. Do you have any history of trauma, especially sexual trauma?
I have not experienced trauma.
Yes, and I would like to share more in person.
Yes, and I would like to share more over email.
Yes, but I do not feel comfortable sharing further.
Previous Pregnancy and Birth Experiences
Total number of pregnancies, including this one
1
2
3
4
5
6
7+
If you have any history of pregnancy, fetal, or infant loss, we want to support you in a way that makes you feel most comfortable. If you have experienced loss, please let us know if and how you feel comfortable sharing.
I have not experienced loss.
I have experienced loss and I feel comfortable sharing during our prenatal visit.
I have experienced loss and I feel comfortable sharing over email.
I have experienced loss, but I don't feel comfortable sharing.
If you do not have previous full term birth experiences, you can skip down to "My Hopes and Preferences".
Please tell us about your previous birth experiences, including where your baby was born, how old they are, what gestational age they were born, and your overall feelings and experiences from that birth experience.
My Hopes and Preferences
During my birth, I really hope I will be able to...
Other than everyone being healthy, one thing that is really important to me is...
During my birth, I really hope my partner will...
I would be really disappointed if...
I am excited for...
I am nervous about...
I hope my doula will help me by...
As part of our group model of care, intern doulas are sometimes brought to births to support clients and learn from primary doulas. Please check this box to acknowledge that you understand that intern doulas may also attend your birth. A primary doula will always be present.
*
You did it! Thanks so much for completing this form for us. If you have any questions for us about your care, next steps, or class scheduling, please feel free to leave them here for us, and we will reach out soon!
