Booking Form

Doula Questionaire

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Choose One *

Birthing person Support Person Other

In order to better support you and perhaps have you think a little deeper about your upcoming birth, here is a little questionnaire that you can choose to answer as many of the questions as you feel comfortable to share.
It is beneficial for all attending the birth to have a think about these areas to better be present to the story unfolding with this baby. I look forward to your answers. Jo

Name *

First

Last

Email *

Phone Number *

Partner/Support peoples names *

Baby's guess due date *

Intended place of birth & if known care provider *

Your residential address *

Line 1

Line 2

City

State

Zip Code

Country

History

How did you feel when you first found out you were pregnant? How do you feel now? *

Previous Birthing History *

Previous Pregnancy History *

How did you feel about your menarche? What is your relationship with your bleeding cycle? *

If you know, how you were born? What is your birth story? And that of any older siblings. *

Is there anything in your history you feel I should know? *

relationship

How did you and your birthing partner meet? *

How would you describe your relationship with your birthing partner? *

Intentions

Any Previous or planned Childbirth Education? *

What is important to you about how you birth this baby? *

Share any Moments of challenge in your life *

Describe any interactions with the hospital system *

How would you best like to be supported by me? *

Is there anything else you would like to share? *

By submitting this form you acknowledge that you are engaging in my doula services to develop a relationship with you during pregnancy, to conceptualise your ideal birth and to develop your birth plan. During labour I will help to maintain the best birthing environment that you need to enhance the process of your labour. I will support you physically, emotionally and help you to work through decisions that may need to be made during the journey. All these services do not include clinical or medical support or advice regarding your perinatal care.

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