Client Intake Form Client Intake FormI’m looking forward to working together! Please fill out the information below so I can provide the best support possible. General Information Name * First Name Last Name Your preferred pronouns * She/Her He/Him They/Them Other Partner/Support Person's Name if applicable First Name Last Name Your partner/support person's preferred pronouns if applicable She/Her He/Him They/Them Other Your email address * Your phone number * (###) ### #### May I text you? * Yes No Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact * First Name Last Name Emergency Contact's Phone * (###) ### #### Estimated Due Date * MM DD YYYY Care Information Care Provider's Name and Organization * Preferred Birthing Location * Preferred Birthing Location Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Personal History Do you have any allergies? Please list any current health conditions (mental and physical) that may impact pregnancy or birth. Number of previous births, including stillbirths Types of previous birth(s) Vaginal C-section, scheduled C-section, unplanned VBAC Other Please list any health conditions developed during past pregnancies. Current Pregnancy Baby's Sex Male Female Both - for multiples Unknown Baby's Name Please let me know if sex and/or name should be kept secret. Please describe how this pregnancy experience has been so far, both physically and emotionally. Have you taken any childbirth education classes? Please list date and location. What is your ideal birth vision? Describe what a perfect birth experience looks and feels like for you. Have you made a birth plan? If not, we can do this together. Have you packed a birth bag? If not, we can do this together. When does your care provider want you to call them/arrive at the birthing location? Have you discussed protocols if you go past your due date? What do you anticipate will be your greatest strength in labor? What do you anticipate will be your greatest challenge in labor? In what ways do you hope a doula's support will be of help to you? In previous painful/challenging situations (e.g., sickness, migraine, surgery), what have you found comforting? What DOESN'T soothe you? What do you want me to NOT do? e.g., particular scents, words/phrases, touch, etc. How does your partner/support person want to be involved in the labor? e.g., hands on, sharing support with the doula, following the doula's lead Do you have any religious, spiritual, or cultural beliefs or customs that you would like me to be aware of? Additional Information Do you need more information on any particular topic? e.g., C-section recovery, nursing/chestfeeding, postpartum depression/anxiety, infant massage, diet, etc. Please share anything else you feel I should know about you, any questions you may have, or any additional topics you'd like to discuss. How did you find Balsam & Pine? Photography Release I am more than happy to take photos for you as I am able. From time to time, I may update my website and social media profiles with these (non-explicit) photographs, with your consent. Please let me know your preference below regarding photography. Yes, I consent. Feel free to use (non-explicit) photos from my labor, birth, and the immediate postpartum period. Yes, but please let me know which ones before you post. No thank you, I'd like to keep these photos private. Let's discuss further. Thank you! Your form has been submitted.
