TLC Doula Service

  • Client Intake Form

    Thank you for taking the time to fill this out. If you have any questions, don't hesitate to ask.

  • Full Name:*
  • Due Date:*
  • Email Address:*
  • Primary Phone Number:*
  • Other Phone Numbers:
    If none, leave blank.
  • Your Date of Birth:
  • Address:
  • Partner's Name:
  • Partner's Phone Number:
  • Other Support People:
    Give the names and phone numbers of any other people who will be on your birthing team.
  • Name of Doctor or Midwife:*
  • Doctor or Midwife Phone Number:
  • Birth Location:*
  • Name of Backup Birth Location:
    If you have one
  • Have you toured your birth location?
  • Do you plan to breastfeed?*
  • Is this your first pregnancy?*
  • Tell me about your other pregnancies and births:
    i.e. Tell me any pertinent information, gestation at birth, induction, complications, etc. And how many times you have been pregnant.
  • Do you have any health conditions?*
  • Please list your health conditions and describe how they affect your pregnancy and delivery if applicable.
  • List any medications you are taking and any allergies you have:
  • Do you have any communicable diseases? *
    This includes STD's, viruses, rashes, HIV/aids, Hepatitis, etc.
  • List any communicable diseases you have
  • Have you used any illicit drugs during your pregnancy?*
  • Do you have a birth plan prepared?*
    Please email me your birth plan if/when you have it ready. If you do not have a plan, I can help you create one.
  • What type of a birth are you planning for?*
    Water birth, natural, vaginal, epidural, c-section, induction. Tell me about your ideal birth experience.
  • What are your concerns for your upcoming birth?*
  • Is there anything I should be aware of as your doula in order to provide you the best possible care?
    Do you have any special concerns or questions you would like us to discuss during our visit?
  • Because of the unique challenges of birth, it is possible that a prior trauma or violent incident can impact your birth experience. By being aware of this, I can better serve you.
    Any information you choose to share with me will be kept absolutely confidential. Due to the sensitive nature of this topic, we can discuss this during our visit. Or, if you prefer, you can share any concerns here.
  • Do you have any other questions, comments, or concerns?
  • Mandy Andrews is collecting this information as it pertains to your case only. She will never divulge your private information to anyone without your express consent.

  • Security Code*

     

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