Birth Culture Birth Client Intake

Personal Information

First Name *

Last Name *

Prefered Pronouns

Date of birth *

Race *

Ethnicity *

Address

Street Address

City

State

Country

Postal Code

Phone *

Email *

Partner/Support Person Information

Partner First Name

Partner Last Name

Partner Phone

Partner Email

Partner Pronouns

Pregnancy Information

Estimated Due Date *

Current Pregnancy Count *

What number pregnancy is this?

Number of Fetuses *

Medical Info Summary

Pregnancy Complications

Select all that apply

Allergies

Previous Pregnancies & Births

Start from most recent

‼️If current pregnancy count is '1' skip this section.

Previous Pregnancy 1 Year

Previous Pregnancy 1 Outcome

Previous Pregnancy 1 Notes

Previous Pregnancy 2 Year

Previous Pregnancy 2 Outcome

Previous Pregnancy 2 Notes

Previous Pregnancy 3 Year

Previous Pregnancy 3 Outcome

Previous Pregnancy 3 Notes

Previous Pregnancy 4 Year

Previous Pregnancy 4 Outcome

Previous Pregnancy 4 Notes

Birth Plan & Preferences

Desired Birthing Location

Home

Hospital

Birthing Center

Unsure

Specific Birth & Newborn Preferences

Select all that apply. These help your doula and care team understand your wishes for immediate postpartum care and early bonding.

Preferred Birth Plan

*Select all clinical pain-management and delivery preferences — informs practical planning and preparation.

Newborn Feeding Preference *

Select all that apply for planning resources and guidance.

Cultural/Identity Considerations

Support System

Maternal Support System *

Client Expectations & Goals

Hopes for Birth *

Emotional, relational, and experiential atmosphere — what the client hopes to feel or experience.

Hopes for Birth (Other)

Concerns or Fear

Concerns or Fears

Concerns or Fears (Other)

Expectations from Doula

Expectations from Doula *

Select all that apply

Other Expectations for Doula

Additional Information

Primary Language *

How did you hear about us?

Referral Source *

Other Notes

Emergency Contact

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relationship