Confidential Client Intake Form

Expectant Parent's Name(required)

Partner's Name(required)

Address(required)

City(required)

State(required)

Zipcode(required)

Phone Number(required)

Email address(required)

Baby's DOB or EDD(required)

Doctor or Midwife(required)

Place of delivery(required)

First baby(required)

Yes

No

Date of Birth(required)

Goals for your upcoming birth

Do you have Medi-Cal or are low-income?(required)

Yes

No

What is your Medi-Cal ID?

Service interested in (check all that apply)

Birth Doula Support

Postpartum Doula Support

Breastfeeding Support Only

Childbirth Education Classes – Group

Childbirth Education Classes – Private

Breastfeeding Education Classes – Group

Breastfeeding Education Classes – Private

Placenta Encapsulation

Birth Options Consultation/Pre-Conception Counseling

Are you requesting Lactation Support Services only?

Yes

No

Maybe

What breastfeeding issue(s) are you having?

If requesting Doula, do you have an ethnic or racial preference for your doula? Please specify,(required)

We aim to be receptive to our client's needs, so if you have a racial or ethnic preference for your doula, please let us know. Choose from drop-down menu.

Do you prefer a LGBTQIA+ doula?(required)

Yes

No

Doesn't Matter

Are you interested in participating in Parent Support Groups for Fathers or Mothers or LBGTQIA+ Parents?

Yes

No

Not now, maybe later

If yes, which support group interests you?

Mother’s Support Group

Father’s Group

LBGTQIA+ Parent Support Group

Are you interested in participating in a prenatal or postpartum yoga class (offered over Zoom)?

Yes

No

Not now, maybe later

Educational interests

Additional Questions Due to COVID-19

Are you comfortable with in-person appointments or do you prefer virtual support? (required)

In-Person

Virtual

Both

Does your medical or midwifery provider restrict the number of persons that can be present at your birthing facility?(required)

Yes

No

Unsure

Do you require COVID-19 testing for doulas who work with you?(required)

Yes

No

Have you or anyone in your household tested positive for COVID-19?(required)

Yes

No

Other Information

PARENT REQUEST FOR DOULA & LACTATION SERVICES

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