Birth Doula Intake Form

Client Information

Full Name

Preferred Name/Pronouns

Date of Birth

Age

Home Address

Phone Number

Email Address

Military Service Information

Military Status

Active Duty

Military Spouse

Not Applicable

Branch of Service

Rank/Grade

Base/Installation

Unit Assignment

Chain of Command Contacts

Provide contact information for four members of your chain of command for emergency notifications.

1. Immediate Supervisor

2. Second Level Supervisor

3. Unit Commander/Department Head

4. First Sergeant/Senior Enlisted

Upcoming Deployments or Training (within next 6 months)

Insurance & Healthcare Information

Primary Insurance

TRICARE

Medi-Cal

Other

Insurance ID Number

Group Number (if applicable)

Primary Care Provider

OB/GYN Provider

Medi-Cal Specific Information

County of Coverage

Managed Care Plan

Pregnancy & Birth Information

Due Date

Current Weeks Pregnant

Planned Birth Location

Number of Previous Pregnancies

Number of Previous Births

Number of Living Children

Type of Birth Desired

Vaginal Birth

Planned Cesarean

VBAC

Undecided

Previous Birth Experiences

Support System & Birth Team

Partner/Support Person Name

Relationship to Client

Partner Phone Number

Partner Email

Additional Support People (family, friends who will be present)

Childcare Arrangements During Labor/Birth

Emergency Contacts

Primary Emergency Contact

Secondary Emergency Contact

Medical History & Current Health

Current Pregnancy Complications or Concerns

Medications & Supplements

Allergies & Dietary Restrictions

Mental Health History & Support

Birth Preferences & Goals

Pain Management Preferences

Medicated

Unmedicated

Labor Support Preferences

Massage

Aromatherapy

Birth Ball

Water Birth/Hydrotherapy

Music

Meditation/Breathing

Cultural or Religious Considerations

Primary Concerns or Fears About Birth

Goals for Birth Experience

Postpartum Planning

Feeding Plans

Exclusive Breastfeeding

Combination Breast & Bottle

Formula Feeding

Undecided

Postpartum Support Plan

Service Agreement & Consent

Preferred Communication Method

Phone Call

Text Message

Email

How did you hear about our doula services?

Additional Questions or Concerns

Consent & Agreement

I understand that doula services are non-medical emotional and physical support, and do not replace medical care from qualified healthcare providers.

I consent to the doula communicating with my healthcare team as needed for continuity of care.

I consent to the collection and use of this information for the purpose of providing doula services, in accordance with HIPAA privacy regulations.

I consent to being contacted for follow-up care and feedback surveys (optional).

Client Signature

Date