Client Intake Form

Please fill out the following sections as completely as possible. Along with this client intake form, kindly read, review and sign the Service Agreement which may be accessed here, if you haven't done so already.

Thank you for taking the time to fill out this form. Having this information prior to our first meeting helps me to utilize our time together more effectively and serve you better. If you have any questions, please do not hesitate to ask.

Please note, this information is private and will not be shared with any parties with out your express consent.

Information about you

* Indicates required field

Name *

First

Last

Pronoun *

Email *

Cellphone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

How did you hear about my services? If you were referred, please let us know so we can say thank you to them! *

Alternate/Additional Support Person (If you have one)

Name *

First

Last

Phone Number *

Your relationship to them *

Will they be taking time off work to be able to support you postpartum? *

Your Family / Household

Do you have older children? If yes, please include their ages and names *

Does anyone else live in your home beside your partner/children? *

Do you have any pets? If yes, what type, their names and their age please *

Are there any allergies or food restrictions in your household? *

Information about your pregnancy + postpartum and baby

Name of your Care Provider *

Baby's Name (if they have one and you want to share it) *

Due Date / Birth Date? *

Please tell me about your pregnancies/births (if already delivered or you have older children) *

If you have not yet given birth, please let me know how this pregnancy is going and what a short synopsis of your birth plans *

Have you and your partner taken any education in preparation for your postpartum period? (Childbirth preparation, breastfeeding, newborn care, infant CPR, etc.): *

Do you plan to breastfeed? *

Yes No I am undecided

Please take this opportunity to list any specific questions or concerns you have related to feeding from your body *

What are your primary goals for having a postpartum doula? *

Is there anything I should be aware of, as your doula, in order to provide the best possible care? *

Because of the unique challenges of pregnancy, birth and postpartum, it is possible that a prior trauma or violent incident can impact your experience. By being aware of this I can better serve you, however, please share only what you are comfortable with.

Do you have a history of depression or other emotional disorders? *

Do you have any fears about your upcoming birth, postpartum, or parenting? *

Do you have any cultural or religious belief you would like me to be aware of that might affect my care for your family? *

Do you have any other questions, comments or concerns? *

Submit

HOME ABOUT. DOULA. CLASSES CONTACT

Proudly supporting postpartum families in Pitt Meadows, Maple Ridge, Port Coquitlam, Coquitlam. Port Moody, Langley,
Surrey and New Westminster.

Filled with gratitude to be living and working in the unceded and ancestral home of the Katzie, Kwikwetlem, Matsqui, Kwantlen, and
Semiahmoo First Nations.

Postpartum Client Intake Form

Information about you

​Alternate/Additional Support Person (If you have one)

Your Family / Household

Information about your pregnancy + postpartum and baby

Alternate/Additional Support Person (If you have one)