Your name
*
First Name
Last Name
Your preferred pronouns:
Do you identify as Aboriginal or Torres Strait Islander?
Do you identify as LGBTIQ+?
Your home address
If you have booked an online session, please just enter your postcode below.
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Your email
*
Your phone number
*
(###)
###
####
Preferred method of contact:
Other:
Partner/Support persons name (if applicable)
First Name
Last Name
Partner/ support persons preferred pronouns:
Do you identify as Aboriginal or Torres Strait Islander?
Do you identify as LGBTIQ+?
Partner/Support persons phone number
(###)
###
####
Partner/Support persons email
Preferred method of contact:
Other:
Your estimated due date
MM
DD
YYYY
Do you have a primary maternity care provider chosen for your birth? If so, who? If not, would you like to discuss choosing a primary care provider that will best fit your needs?
How are conversations going with your provider? Do you feel heard, respected, that you can ask questions, and so on? Do you have any concerns or questions on how to approach certain topics?:
If you have had previous pregnancies, what were the outcomes? Please include as many or as little details as you’d like.
i.e. vaginal birth, cesarean birth, birth before term, VBAC, multiples, loss, etc.
Please describe your physical and emotional prenatal and pregnancy experience so far:
Have you experienced any complications with this pregnancy so far? Do you have any restrictions or medications from your care provider regarding this pregnancy?
Is there anything in your personal history that might make it more challenging for you to cope with the experience of labour?
If yes, please share any pertinent details below:
Do you have any allergies?
i.e. food, medication, latex etc
Have you created a birth 'map' or established your labour / birth preferences?
If not, we can spend some time exploring this together
Who would you like to be present during your labour?
Select all that apply
Do you feel comfortable with everyone on your birth team? Are they supportive of your decisions?
How does your partner/ support person(s) want to be involved in your birth?
What are your thoughts about coping tools and pain management during labour? Have you considered it? If yes - what options have you been looking into?
Do you have any concerns and/or fears regarding your birth? Does your partner/support person(s)?
What are you most excited about for this birth? And your partner/support person(s)?
Do you have any beliefs or traditions that you would like to be respected and included during your labour and birth?
i.e. religeous, spiritual, philosophical etc.
In what ways are you already preparing for childbirth during this pregnancy?
i.e. other classes, books, websites, therapy, movement etc.
Do you plan to take any additional classes to prepare ?
(ie. breastfeeding, newborn care, infant CPR, etc.)
Are there specific topics you would really like to learn more about?
In what ways are you already preparing for postpartum? If you're feeling a little lost with this, would you like some guidance?
i.e. books, classes, meal train, mental health support, lactation consultant etc.
How do you plan on feeding your baby?
If you plan on another method of feeding your baby, please explain below:
Do you feel that you have a supportive community in the area? If not, what can I do to help you feel supported?
How much, and how well are you sleeping during this pregnancy?
We all navigate different levels of intensity in our lives. How would you describe your current emotional landscape, and what supports you in finding moments of peace?
Lastly, in what ways do you hope a doula's support will be helpful to you in birth and/or postpartum? What types of assistance do you imagine will be most useful for you?
