Intake Form for Bon Fete Doula Clients

Full Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Can we text?*

Best Time of Day to Contact*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Estimated Due Date*

MonthDayYear

E-mail*

Partner's E-mail

Marital Status

Partner's Name

Emergency Contact*

Emergency Contact Phone Number*

Birth Location*

Care Provider Name*

Care Provider's Phone Number

How did you here about us?

Are you experiencing any of the following? (Please check all that apply)

If you checked any of the options above, please detail below:

Who will be attending the birth?

What medications or vitamins are you taking?

Are You Considered High Risk?

YesNo

If YES please explain

Will this be a Vaginal Birth After a Cesarean?

YesNo

Have You Taken a Birth Class?

YesNo

If YES which class/classes?

Do You Plan To Breast Feed?

YesNo

Have You Taken a Breast Feeding Class?

YesNo

If YES which class/classes?

Do you do any of the following? (Please check all that apply)

If you checked any of the options above, please detail below:

Do you have any allergies?

Is there anything else you would like to share with me about your physical or mental health that would help me serve you better?

Do you have any physical or emotional aspects of preparation for birth that you would like information or support with?

Do you have physical help or meals for the immediate postpartum period?

Are you having any discomforts? (back pain, heartburn, etc)

Do You Have Any Questions?

Scope

A) Services Rendered. The doula accompanies the woman in labor, provides emotional and physical support, suggests comfort measures, and provides support and suggestions for the partner. Whenever possible, the doula provides pre- and post-partum emotional support, including explanation and discussion of practices and procedures, and assistance in acquiring the knowledge necessary to make informed decisions about her care. Additionally, as doulas do not "prescribe" treatment, any suggestions or information provided within the role of the doula must be done with the proviso that the doula advises her client to check with her primary care provider before using any application.

B) Limits to Practice. Doula Certification apply to emotional and physical support only. A certified doula does not perform clinical or medical tasks such as taking blood pressure or temperature, fetal heart tone checks, vaginal examinations, or postpartum clinical care. If doulas who are also health care professionals choose to provide services for a client that are outside the doula’s scope of practice, they should not describe themselves as doulas to their client or to others. In such cases they should describe themselves by a name other than "doula" and provide services according to the scopes of practice and the standards of their health care profession. On the other hand, if a health care professional chooses to limit her services to those provided by doulas, it is acceptable according to DONA International’s Standards for her to describe herself as a doula.

C) Advocacy. The doula advocates for the client's wishes as expressed in her birth plan, in prenatal conversations, and intrapartum discussion, by encouraging her client to ask questions of her care provider and to express her preferences and concerns. The doula helps the mother incorporate changes in plans if and when the need arises, and enhances the communication between client and care provider. Clients and doulas must recognize that the advocacy role does not include the doula speaking instead of the client or making decisions for the client. The advocacy role is best described as support, information, and mediation or negotiation.

D) Referrals. For client needs beyond the scope of the doula’s training, referrals are made to appropriate resources.

Intake Form

Personal Information

Personal History

Social History

Bon Fete Doula Services' Scope of Practice