Doula Support Intake Form

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Address

Location of Birth/Postpartum Care (City, State, Country)

Planned Travel Dates for Doula Services (Arrival & Departure)

Type N/A if in Raleigh, NC

Nearest Major Airport

N/A if in Raleigh, NC

Transportation from Airport to Your Home/Birth Location

Provided by family

Ride-share/Taxi

Rental Car

Other (Please Specify)

Accommodation Arrangements

Staying with Family (Private room for Doula)

Hotel/Airbnb

N/A If in Raleigh, NC

Other (Please specify)

Expected Due Date

Place of Birth (Hospital, Birth Center, Home)

Type of Birth Planned (Vaginal, Cesarean, VBAC, etc)

Birth Preferences (natural birth, pain management options, etc.)

Any Complications or High-Risk Factors During Pregnancy?

Yes

No

If yes, please provide details

Preferred Start Date for Postpartum Doula Support

Requested Hours (Daytime, Overnight, Specific Days/Times)

Primary Postpartum Concerns/Focus Area (breastfeeding support, emotional support, newborn care, sibling care, etc.)

Are there any specific cultural or religious practices you would like respected during postpartum care?

Please list all members of the household and their relationship to you/baby

Are there any siblings? (if yes, list names & ages)

Are there any pets in the home? (If yes, specify type, breed, temperament)

Do you expect frequent visitors during the postpartum period? (If yes please specify how you would like the doula to handle visitors)

Are there any weapons in the home? (If yes, are they securely stored?)

Are there any safety concerns or history of domestic violence in the home? (If yes, please provide any information you feel is relevant)

Is anyone in the household currently undergoing treatment for substance abuse? (If yes, please explain)

Is smoking allowed in the home? (If yes, please describe where smoking is permitted)

Do any household members have any medical conditions or disabilities that the doula should be aware of? (If yes, please describe)

Are there any known allergies (pets, food, medication) that the doula should be aware of? (If yes, please describe)

Is anyone in the home currently sick or experiencing symptoms of illness? (If yes, please explain)

Is there anything else you would like us to know to ensure the best birth and postpartum experience for your family?

How did you hear about my doula services?

I acknowledge that the information provided is accurate and that it will be used to ensure a safe and supportive environment for the doula and my family.

Yes

No

Signature

Date and time

Month

Day

Year

Time

:

I agree to pay the full amount of $3,500 once the agreed upon contracts have been signed?

I agree

Pay Now (If Both Parties Have Agreed, Skip Until Then)

Birth/Postpartum Doula Support$3500

We Ship Every Tuesday & Thursday!

Birth/Postpartum Support Doula Intake Form

Please complete the following form before purchasing Birth and/or Postpartum Doula Support
email info@ausetherbals.com with questions

We Ship Every Tuesday & Thursday!

Birth/Postpartum Support Doula Intake Form

Please complete the following form before purchasing Birth and/or Postpartum Doula Support email info@ausetherbals.com with questions

Please complete the following form before purchasing Birth and/or Postpartum Doula Support
email info@ausetherbals.com with questions