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Client Intake Form

We're so glad you're here. This form helps us understand your needs so we can connect you with the right support. All information is kept confidential.

First Name *

Last Name *

Pronouns

Phone Number *

Email Address *

Street Address

City

State

ZIP

Estimated Due Date

OB/Midwife Provider Name

Planned Birth Location

Number of Previous Births

Tell us about any previous birth experiences (optional)

What kind of support are you looking for? (Select all that apply)

Prenatal support visitsLabor & birth supportPostpartum supportBreastfeeding/chestfeeding supportChildbirth educationBirth planningEmotional supportCommunity resource navigationAdvocacy during care

What are your birth goals or intentions?

What concerns or fears do you have about your pregnancy or birth?

Consent & Privacy

I consent to be contacted by Doula Lab via phone or email regarding my intake and services. *I consent to Doula Lab sharing relevant information with my healthcare provider(s) to coordinate care.

Your information is kept strictly confidential and is never sold or shared with third parties outside of direct care coordination. See our privacy policy for details.

EIN # 92-3697049 | 501(C)3

6608 W. Main St
Belleville, IL 62223

(618) 213-6800 · [email protected]

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