Doula Client Intake Form
Comprehensive intake for birth and postpartum doulas — pregnancy history, birth preferences, support team, and emergency contacts.
What's inside
- Pregnancy + prior birth history
- Provider + place of birth
- Support team contacts
- Birth preferences summary
- Photo & consent
DOULA CLIENT INTAKE Client name: ______________________________ Partner name: ____________________________ EDD: __________ Pregnancy #: ____ Living children: ____ PROVIDER & PLACE OF BIRTH OB/Midwife: ______________________________ Hospital / birth center / home: __________________________ MEDICAL HISTORY (brief) Previous births (type/outcome): __________________________ Current health conditions: __________________________ Medications: __________________________ SUPPORT TEAM Partner phone: ___________ Backup support: ___________ Pediatrician: __________________________ BIRTH PREFERENCES (1-line summary) Pain management: __________________________ Movement / position: __________________________ Newborn procedures: __________________________ PHOTOGRAPHY CONSENT [ ] I authorize the doula to take labor / postpartum photos for my use only. [ ] I authorize photos for the doula's portfolio (faces blurred). Client signature: ___________________________ Date: __________ DISCLAIMER: This template is provided for informational purposes only and does not constitute legal, medical, or financial advice. Have a licensed professional in your jurisdiction review and adapt it before use.
FAQ
Is this HIPAA-compliant?
Doulas aren't typically covered entities, but treat all client info as protected. Beautifyx encrypts intake at rest and audits access.
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Use doula client intake form inside Beautifyx — auto-sent, e-signed, stored with the client.
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