New Client Intake Form Fill out our intake form below so we can have all of your basic information in order to support you during your pregnancy, birth, and beyond. Name * First Name Last Name Who is your doula? Kahla Jurney Natalie Portman Estimated Due Date * MM DD YYYY Email * Phone * (###) ### #### Home Address Address 1 Address 2 City State/Province Zip/Postal Code Country Age What do you do for a living? Partner’s Name First Name Last Name Partner’s Relationship To You (husband, boyfriend, mother, sister, etc.) Partner’s Phone (###) ### #### What service(s) are you interested in? * Birth Doula Support Childbirth Education (Online) Childbirth Education (Group In-Person) 1:1 Body Assessment Private Coaching Call Virtual Birth Doula Support Planned Location for Delivery * Medical Provider’s Name or Practice's Name * Baby’s Gender Boy Girl Unknown Do Not Wish To Disclose Baby’s Name (if known and you care to disclose) Planned Method of Feeding Baby Exclusive Breastfeeding Exclusive Formula Feeding Combination Breastmilk & Formula Exclusive Pumping Any complications during this (or other) pregnancies? Have you given birth before? No Yes, Vaginally Only Yes, Cesarean Only Yes, Vaginally & Cesarean If yes to previous, how many times have you given birth before? 1 2 3 4 5+ Who would you like present for the labor and birth? (not including medical provider/staff) Partner Doula Mother Mother-In-Law Sister Friend Photographer/Videographer Other What is your hope or vision for this birth? Do you have any specific beliefs, values, or practices you’d like to include in your birth experience? (We are Christian doulas and love incorporating faith into this journey, but we gladly support all families.) If yes, please explain What is your physical activity level currently? Are you sitting most of the day? Do you workout regularly? What type of activity do you do? Are you experiencing any aches and/or pains due to pregnancy? Any questions or concerns at this time? Thank you for taking the time to fill out my intake form! I look forward to reviewing your answers and connecting with you soon!
