Client Templates

Intake, Planning & Care — The Doula Lab · Template Version 1.0

Template 1

Inquiry Questionnaire

Complete at first contact, before a consultation is scheduled.

Contact information

Full name*

Preferred name

Pronouns

Date of inquiry

Phone

Best time to reach you

Email*

Preferred contact method

City

ZIP code

Partner or support person

Their relationship to you

Contact safety

Your pregnancy

Estimated due date

Weeks pregnant today

Is this your first baby?

Number of previous births

Are you expecting multiples?

Prenatal care provider

Where you plan to give birth

Name of facility, if known

Provider type

What kind of support are you looking for?

What matters most to you

What are you hoping for in this birth? What are you worried about?

Is there anything about a previous birth or pregnancy that shapes what you want this time? Share only what you are comfortable sharing.

Practical details

Languages spoken at home

Interpretation needed?

Accessibility needs

Do you have insurance?

Health plan name

Reliable phone and internet?

Support you might need

Tick anything you would like help with — there is no wrong answer and it will not affect the care you receive. You can skip this section entirely.

If you are not safe

If you are afraid of someone in your home, or someone is controlling your money, your phone, or your medical care, you can tell us. We will connect you with a trained advocate. If it is not safe to discuss this in writing, leave this blank and tell your doula in person when you are alone. We will ask you privately.

Payment

How did you find us?

Anything else you would like us to know

For office use only

Date received

Received by

Consultation scheduled

Assigned to

Eligibility verification requested

Verification result

Outcome

Notes