APOTHECARY
SPIRITUAL WELLNESS SERVICES
1:1 COACHING
INTEGRATIVE HERBAL SERVICES
INTUITIVE YOGA & GUIDED MEDITATION
CRYSTAL ENERGY & REIKI HEALING SERVICES
HOLISTIC DOULA CARE
EVENTS | CLASSES
THE DESIGNATED HEALER PODCAST
THE DESIGNATED HEALER BLOG
HOLISTIC DOULA SERVICES- CLIENT QUESTIONNAIRE
more about holistic doula services
please complete this form before your initial consultation
CLIENT INFORMATION
*
Indicates required field
Legal Name
*
First
Last
Phone Number
*
Email
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Are you carrying multiples?
*
Yes
No
Other
Preferred Name
*
First
Last
Age
*
Birthday
*
SUPPORT PERSON ATTENDING BIRTH
Name
*
First
Last
Phone Number
*
EMERGENCY CONTACT
Name
*
First
Last
Phone Number
*
Due Date
*
Child's Gender
*
Female
Male
Prefer not to say
BIRTHING DETAILS
Address of Hospital or Birthing Center
*
Line 1
Line 2
City
State
Zip Code
Country
Back Up Birthing Location
*
Desired Birthing Method
*
Natural (No Medication Intervention, No Medication)
Medicated/ Open to Medical Intervention
Home Birth
Hospital Birth
Water Birth
Which Doula Services are you interested in?
*
Antepartum Doula Services
Birth Doula Services
Postpartum Doula Services
PER DIEM (Hourly) Doula Services
Services Bundles
choose all that apply.
Please specify which doula services you are interested in (services available at per diem, hourly, or per service rates)
*
Custom Birth Plan
Custom Labor Comfort Plan
Nutrition Planning
Nursery Planning
Nursery Preparation
Infant Care Support
Breastfeeding Support
Postpartum Comfort & Recovery Support
Birth Attendance
Transitional Consultation
REPRODUCTIVE HISTORY
number of pregnancies:
*
number of births:
*
Number of and names of Sibling(s) at home
*
Any history of perinatal or postpartum depression? Or any other birthing- onset mental health issues?
*
Is there a history of infertility, pregnancy loss, or other birth trauma?
*
Briefly describe your birthing and postpartum recovery expectations
*
I agree to receiving marketing and promotional materials
Submit questionnaire
APOTHECARY
SPIRITUAL WELLNESS SERVICES
1:1 COACHING
INTEGRATIVE HERBAL SERVICES
INTUITIVE YOGA & GUIDED MEDITATION
CRYSTAL ENERGY & REIKI HEALING SERVICES
HOLISTIC DOULA CARE
EVENTS | CLASSES
THE DESIGNATED HEALER PODCAST
THE DESIGNATED HEALER BLOG