Client Intake Form 

If you will be using me as your doula, please take some time to fill out and submit the client information form below prior to our first prenatal visit. This information is kept secure & confidential. We will have the opportunity to go over the information you've provided at our visit.

If you find a question does not apply to you, please answer with N/A; if you find that you don't have an answer for the more introspective questions, please consider allowing yourself to sit with the question to see if anything comes up. Those responses allow me to better understand what your needs & wants are in your birth experience & how I can help you achieve that. 

Contract (including Payment, Cancellation and Refund Policies) *

Contract (Including payment, cancellation, and refund policies) *
I have read and agree to the terms and conditions as set out in the Letter of Agreement describing the Doula Services provided by Jennifer Lynn Frye. (If you have any concerns or questions about the terms outlined in the contract, please contact me before agreeing.)
Name *
Name
Partner's Name
Partner's Name
Birthing Individual's Birthdate *
Birthing Individual's Birthdate
Estimated Due Date *
Estimated Due Date
Phone *
Phone
Additional Phone
Additional Phone
if applicable
Home Address *
Home Address
Is this your first pregnancy? *
Are you taking prenatal education classes? *
i.e. Hospital, Birth Center, Home birth- If Hospital, please specify which facility & whether you have registered/toured
Accupuncture, TCM, Chiropractor, etc
Health History
To your knowledge, do you have or have you had any of the following: *
Childbirth History
Please complete this section if applicable. If not, leave blank.
i.e. abortion, miscarriage, infertility, stillbirth or children placed for adoption
gender, weight, birthdate, name
Vaginal or Cesarean? How did your labor begin? How long did it last? How did you push? What coping techniques did you use? Did you breastfeed/formula feed/both?
Complications with the birth itself, immediate health of baby/you, with breastfeeding, etc.
Upcoming Birth
Do you want or have you written a birth vision/plan?
Doula/Client Logistics
unlimited phone, email, & text come with my service to you, in addition to our face to face meetings.
Please mark any items that you would like to discuss during our visits
This allows me to prepare accordingly & provide you with the best information.