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The Birthing Lady
Doula & Postpartum Support
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New Client Questionnaire
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Name
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First
Last
Email
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Phone
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City & State
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Helps us plan the best support in your area
What's your Estimated Due Date
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Birth Place
Hospital
Birthing Center
Home birth
Other
Do you have any spiritual or faith preferences in your family? Share what would be most helpful for our care.
Are you planning to take any childbirth classes?
Share your thoughts on classes. What are you interested in or hoping to learn before your birth?
How is your pregnancy progressing? Check any that apply.
Normal with no complications
High Risk
Some minor complications, but no current concerns
Other
Describe past birth experiences.
What are some of the positives and negatives you have experienced so far.
What are some of the fears and worries during this pregnancy and birth?
Describe your dream birth experience.
What are your biggest needs or concerns during your Postpartum period?
Why is it important to you to have a Doula and Postpartum care?
This is my first birth and I’d like more support
I want something different from my last experience
I need extra confidence and support to achieve my birth goals
I want a Doula to be a part of my birthing team
Where did you find us?
Yelp
Doula Match
Google Search
Referral
Other
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