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AIW Doula Experience

Client Intake Form

Thank you for your interest in AIW Doula Experience 🤍

This form helps me better understand your needs, preferences, and how I can best support you throughout your pregnancy, birth, and postpartum journey.

Please complete the form below and I will follow up with you shortly.

Client Information

Full Name

Phone Number

Email

City & State

Preferred Method of Contact

How would you like the doula to contact you for follow up?
Untitled checkboxes field

Pregnancy Details

Estimated Due Date

How many weeks gestation are you?

Have you had your first prenatal appointment?

Have you had your first prenatal appointment?
A
B

Medical Provider Type

Medical Provider Type
A
B
C

Birth Location

Birth Location
A
B
C
D

Care & Support Needs

Is this your first pregnancy

Is this your first pregnancy
A
B

Previous birth experiences

What kind of birth experience are you hoping for?

Preference & Concerns

What are your biggest concerns about labor or birth?

How would you like to feel during this birth experience?

Birth Preference

Birth Preference
A
B
C
D

Any medical conditions?

Any emotional, mental or social support needs?

Any emotional, mental or social support needs?

Which service are you interested in?

Which service are you interested in?

***Payment plans available. Medicaid certification pending approval.

Preferred support format?

Preferred support format?
A
B
C

Investment + Commitment

Do you need a payment plan?

Do you need a payment plan?
A
B

Payment type?

Payment type?
A
B