Your Name
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First Name
Last Name
Your Partner's Name
First Name
Last Name
Email
*
Phone Number
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(###)
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Partner's Phone Number
(###)
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Home Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Doctor / Midwife / Practice Name
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Delivery Location
Estimated Due Date
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MM
DD
YYYY
Are you expecting multiples?
Baby's Gender
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Do you have a a name picked out? You can share it with me here if you'd like
Do you plan to share the name with others?
What is your planned method of feeding?
If Applicable: Enneagram for you and your partner?
Have you given birth before?
Have you had any difficulties/complications/restrictions (physical, emotional, or other) with and during this pregnancy?
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What has your birth prep looked like so far? Have you taken or are you planning to take any childbirth classes? If so, please list them below
Ex: Breastfeeding, Infant Care, Infant CPR, Birthing Class..
Do you or your partner have any fears about this birth?
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Do you have any specific scripture or affirmations you are focusing on during this season?
What type of birth are you hoping for?
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Do you have a birth plan/vision?
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What are the three most important outcomes that you desire for this birth?
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What are your expectations of me as your doula?
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What would you partner like me to do to help them be more supportive to you during labor?
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How do you feel about interventions in labor?
Modesty in labor is important to me:
What type of pain management are you looking to use?
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What type of comfort measures would you like to use in labor?
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What topics would you like to spend time covering in our prenatal sessions?
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Any other questions / concerns / ideas you'd like to discuss
