Name(s):

Pronouns:

Address:

Email:

Calls, texts, or emails preferred?

Emergency Contact Name and Relationship:

About Your Pregnancy:

This is baby #:

If yes, for what reason(s) and how long ago?

Name(s) of healthcare provider(s):

Important Medical Information

What is the name of the hospital/birth center?

If other, please specify:

If yes, please specify:

If yes, for what reasons?

Insurance Benefits

Is there anything else you need in order to claim birth doula support in any way? (please specify):

What are your feelings about labour and delivery?

What kinds of sounds and smells are comforting to you?

When you are in pain what types of personal comforts do you like to use? Eg. A quiet room, dim lighting, heat, cold, words of affirmation, etc.

What phrases help you feel powerful? Either when spoken to you or when you say them to yourself?

How would you most like to be supported during labour?

Please list 10 oxytocin releasing activities you'd like to incorporate in your labor

Oxytocin is a natural hormone that stimulates uterine contractions in childbirth and lactation after childbirth.

Anything you would like to add?

In take