Doula Client Intake Form Template [51 questions] | Practice

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Doula Client Intake Form Template

Are you a doula looking for a way to streamline your client intake process? The Doula Client Intake Form Template offers a comprehensive and user-friendly approach to capturing all the necessary information from your clients before their first appointment.

This easy-to-use template allows you to store all of your clients’ important information in one secure location. This can help simplify the administration process and free up valuable time that can be spent with clients. The form allows you to collect contact and personal information, medical history, and preferences. Additionally, there is space to include any additional questions that are specific to your practice.

Whether you are just starting out as a doula or have been in the business for years, the Doula Client Intake Form Template is a great way to create an efficient and secure client intake process.

Doula Client Intake Form Template

Full Name:
Date of Birth:
Home Address:
Phone Number:
Email Address:
Partner Name:
Partner Phone Number:
Relationship Status:
Emergency Contact Name:
Emergency Contact Phone Number:
Relationship to Emergency Contact:
Healthcare Provider Name:
Healthcare Provider Type:
Healthcare Provider Address:
Healthcare Provider Phone Number:
Desired Birth Location:
Name of Delivery Location:
Address of Delivery Location:
Name and Address of Backup Location (if you plan to deliver at a birth center or at home):
Do you have health insurance?
Do you have any allergies (medication, food, or environmental)? If so, please list them.
Have you had any recent illnesses, surgeries, injuries, accidents, or trauma? If yes, please describe.
Do you currently take any prescription or non-prescription medications (herbs, natural supplements, vitamins, or over-the-counter medications)? If yes, please list the name, purpose, and frequency for each medication.
Do you currently have, or do you have a history of, any of the following medical conditions? Check all that apply.
Do you have, or do you have a history of, any of the following psychological conditions? Check all that apply.
Do you currently see a therapist or counselor?
Will this be your first birth?
How many times have you given birth? (Multiples, including twins or triplets, count as one birth.)
Of your previous pregnancies, how many were to term (37+ weeks)?
How many children do you have? Please list name(s) and ages.
Have you ever given birth to multiples (twins, triplets, etc.)?
What types of births have you experienced?
How long did your previous labor(s) last?
Did you experience any of the following pregnancy-related health conditions in the PAST?
Baby's Due Date:
Are you expecting multiples (twins, triplets, etc.)?
Baby's Gender:
Do you have a name (or names) picked out? If yes, you can share it (or them) here, if you like.
Do you plan to share the name(s) with friends or family before the birth?
Have you taken, or are you planning to take, any childbirth education classes? If so, which classes, and where will/did you attend them?
For what type of birth are you planning?
What are your desired methods for managing pain?
Have you experienced any of the following pregnancy-related health conditions during THIS PREGNANCY? Check all that apply.
Have you had any of the following labs or tests? Check all that apply.
Have you experienced any difficulties, complications, or restrictions (physical, emotional, or otherwise) with and during this pregnancy? If yes, please describe.
Are you planning to breastfeed your baby?
Do you have any religious or cultural beliefs that you would like me to be aware of?
Are there any particular topics or concerns that you would like to focus on during our prenatal visit(s) or conversation(s)?
Please list any persons other than your partner that you want to be a part of your support team.
What are your plans for parental leave from your job?
Notes:

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