Doula Client Visit Forms DOULA CLIENT VISIT FORMS – HMHBA COMMUNITY DOULA PROGRAM These are legacy forms. Please refer to the Staff Resources Page for the new forms. Prenatal Visit Submit this form after each visit.Client First Name*Client Last Name*Name of Doula(s) Present*Doula HMHBA Email Address*Enter your HMHBA email to receive a copy of this form.Client ID*Venice Family Clinic has a unique client ID. It’s their patient record number. *** United Healcare format is the following: UHC in front of the woman's initials. Then first initial, Last initial, woman’s birthday, and year of service. *** For those not receiving services under grants the format is the following: first initial, last initial, woman’s birthday, and year of service. Example: MP941991-2023 Place of Visit*Client HomeHMHBA OfficeCommunityPhone/VideoIs this person a Venice Clinic client?*YesNoDoes this client have United Healthcare Insurance?*YesNoDate of Visit*Weeks of Pregnancy*EDDTopics DiscussedHealth Education DiscussedConcerns/Problems IdentifiedFollow Up PlanReferrals Made?YesNoReferral ReasonDoes the client exercise regularly?*YesNoHow frequently?No. of days per week & for how many minutesWhat type(s) of exercise(s)?Next Appointment Date Next Appointment Time Next Appointment LocationClient StrengthsPsychosocialNutritionalMedicalHealth EducationClient ProblemsPsychosocialNutritionalMedicalHealth EducationReferrals Made ProblemReferred toBarriersOutcomeSendThis field should be left blank Postpartum Visit Submit this form after each visit.Client First Name*Client Last Name*Baby's Date of Birth*Baby's Time of Birth*Baby's Name*Name of Doula(s) Present*Doula Email Address*Enter your HMHBA email to receive a copy of this form.Client ID*Venice Family Clinic has a unique client ID. It’s their patient record number. *** United Healcare format is the following: UHC in front of the woman's initials. Then first initial, Last initial, woman’s birthday, and year of service. *** For those not receiving services under grants the format is the following: first initial, last initial, woman’s birthday, and year of service. Example: MP941991-2023 Is this person a LA GAAINS client?*YesNoPlace of Visit*Client HomeHMHBA OfficeCommunityPhone/VideoIs this person a Venice Clinic client?*YesNoDoes this client have United Healthcare Insurance?*YesNoDate of Visit*Weeks of Pregnancy*Topics DiscussedHealth Education DiscussedConcerns/Problems IdentifiedFollow Up PlanReferrals Made?YesNoReferral ReasonNext Appointment Date Next Appointment Time Next Appointment LocationWhat is the mother's depression score (PHQ-9)?Is the mother breastfeeding?*YesNoMother-Baby BondingHow is the mother-baby bonding process going?*Mother is very aware of and attentive to her babyMother says she feels slightly stressed but her baby makes her smile and laughMother says she feels overwhelmed and anxious by babyMother shows no interest in her babyClient StrengthsPsychosocialNutritionalMedicalClient ProblemsPsychosocialNutritionalMedicalReferrals MadeProblemReferred toBarriersOutcomeSendThis field should be left blank
