Birth Doula Intake Form - Primary Support Person
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| Contract (including Payment, Cancellation and Refund Policies)
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I have read and agree to the terms and conditions as set out in the Letter of Agreement Describing Doula Services (document can be found online at http://AdarBirthServices.com/Letter-of-Agreement-Describing-Doula.doc I am a client of SCBP; this contract does not apply to me. I have not yet chosen my Doula; the contract will come into effect if and when I inform Adar Birth Services that I have chosen one of their birth doulas. If you have any questions or concerns about the Letter of Agreement Describing Doula Services, please contact Adar Birth Services before agreeing.
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| Name
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| Date of Birth
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| Partner's Name
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| Email
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| Home Address
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| Special instructions for getting to your home.
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Please include any special instructions, such as buzzer number, parking tips or details about how to get to your home if it is at all difficult.
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| Phone 1
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| Phone 2
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Please make it easy for us to get ahold of you should we need to.
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| Estimated Due Date
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| Is this your first time being involved in a pregnancy?
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Yes No
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| If no, give a brief description of other pregnancies you have been involved with including your role, who attended the birth (midwife, doctor, friends, family, etc) and what feelings you had about the process.
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| How you are feeling about your partner’s pregnancy right now?
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| How do you feel about becoming a parent? Or, if you already have kid(s), how do you feel about becoming a parent again?
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| Tell me about some of your fears around the birth.
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If you can't think of any fears, please tell me what things you may have heard from other parents about their birth that has made you feel badly for them.
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| If you could support your partner through labour and birth anywhere in the world and in any setting, not having to worry about safety for you, your partner or the baby, where would your fantasy birth take place? Who would be supporting you and what would
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Whether hospital, home or some other planet altogether, whatever feels true for you is the right answer.
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| Please tell me what else you would like me to know to help you in your pregnancy, labour, delivery and postpartum period.
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| I feel ________ about the feeding choices that my partner and I have made for our baby.
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Confident Middling Not confident
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| I feel ________ about helping my partner with feeding our baby (if breastfeeding, how do you feel about helping her with this?).
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Confident Middling Not confident
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| Diapering
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Confident Middling Not confident
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| Bathing
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Confident Middling Not confident
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| Dressing
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Confident Middling Not confident
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| Playing
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Confident Middling Not confident
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| Interaction/communication
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Confident Middling Not confident
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| Common infant health issues (e.g. colic, thrush, jaundice)
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Confident Middling Not confident
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| Coping with stressful times (e.g. crying, fussing, screaming, exhaustion)
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Confident Middling Not confident
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| Use of carseat
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Confident Middling Not confident
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Image Verification
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