Support Person Intake Form

Please do your best to answer each question. The purpose of the intake form is to help me not only support the mother but to provide you with as much support as possible as well.

As a doula, I am not meant to take your place but rather work together as a team for an empowered pregnancy, labor, and birth. I can’t wait to get to learn a bit more and start working with you! —Akasha

Support Person's Name

First Name

Last Name

Birthing Person's Name

First Name

Last Name

Relationship to Birthing Person

What role do you want to take in the birth of the child?

What role do you want the doula to fulfill?

What are your thoughts about the pregnancy and upcoming birth?

What do you anticipate your needs to be for the labor and delivery?

What is your background or experiences related to birth?

Any other information you would like to include so that I may serve and support you best?