Client Information

Congratulations on your pregnancy! Thank you for taking the time to fill out this form so I can get to know you better and have an idea of how you would like to be supported throughout your pregnancy, birth and post partum!

All information provided is strictly confidential.

Full Name: *

Date of Birth *

Estimated Due (Guess) Date *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Birth Partner Details *

About Your Health

Have you given birth before *

Allergies/Current Medications? *

If you have birthed previously, please tell me a little about it. How was it for you? *

Please outline your general health *

How has your pregnancy been so far? *

Please outline any complications you have had with this pregnancy or any special instructions from your care provider *

About Your Birth and Baby

I Plan to have a *

Homebirth Hospital Birth Still Deciding

Primary Care Provider Details *

Baby's Name (If known) *

My Baby's Sex *

Male Female Unknown Prefer not to disclose

Planned method of feeding *

Breastfeeding Formula feeding Both Not sure, I would like some more information

Birth Preperation

Do you have religious/cultural beliefs around birth? *

Do you plan to attend any childbirth education classes? If so, please list. *

What is your vision for this birth? *

How do you feel about interventions in labour/delivery *

What are your expectations of me as your Doula? *

Any other comments, questions or concerns? *

Please have a look at our shop page and decide which level of support you are interested in, then select from the options below.

Package Option *

Premium Advanced Essentials Postnatal care

YOUR CART

Client Registration Form