Mother's Name *
Mother's Birth Date *
Phone Number *
Partner Name (if applicable)
Partner Phone Number (if applicable)
Partner Email (if applicable)
Home Address *
Estimated Due Date *
Singleton or Multiples
One BabyTwinsTriplets or more
Baby Boy or Girl? *
BoyGirlWe don't know yetWe want it to be a surpriseOther
Baby(s) Name (if known)
Any others supporters present for birth?
Have you or do you plan on taking any childbirth/prenatal classes? If so, which ones? If not, why?
Read any books or watched any movies or documentaries? Which ones?
How is pregnancy going so far?
Any complications or other conditions that I should be aware of?
Are you seeing any wellness practitioners for care?
Is this your first pregnancy? *
Yes, first pregnancyNo, I have older childrenNo, I have had a previous miscarriage(s)No, I have older children and previous miscarriage(s)
What kind of support do you need the most in this pregnancy?
Do you have a birth plan or birth preferences? Or would you like help creating one?
If you already have Birth Preferences written out, you can attach here.
What are your feelings regarding medical pain relief and interventions during labor and birth?
Do you have any allergies?
What are you most excited about with this birth?
Any specific concerns or fears?
Do you have any beliefs or traditions you want honored?
Describe previous birth experiences, if applicable.
What is your reasons for wanting the support of a doula?
How does dad feel about having a doula? (if applicable)
What is your expectations of our prenatal visits?
Is there anything specific you want more information about?
A package that is as unique as you!
Creating a package
We are a family in need & need to apply for a scholarshipI would like to bundle more than one service for a greater discountI don't want to create a package, I will just add things as we go
Tell me about what you want me to include in your package?
Birth Class $285Birth Doula $1050Postpartum Doula $30/hourBirth Photography $1050Lifestyle Photography $250
Your unique package! Tell me about your budget and your specific needs, so a I can create a package that's perfect for you!
How did you hear about me? *
DoulaMatch.netInternet SearchFacebookNoCo Doula AssociationReferralOther
Birth DoulaPostpartum DoulaBirth ClassesPhotography
Add me to the Mermaid Mama email list*
Yes please!No thank you!