Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
Is it okay to contact you via text, if needed?
*
Where do you live?
How did you hear about us?
I am interested in...
I will be 40 weeks on this date (or, the birth occured on this day):
MM
DD
YYYY
My partner's name is:
First Name
Last Name
My medical provider (MW/OB) is:
My planned birthing location is:
Tell Camille about your hopes for doula support...
Consider sharing:
1. What has you seeking a doula?
2. What qualities do you seek or envision in your ideal doula?
3. How do you envision working together prenatally, and toward what goals?
3. How do you envision a doula supporting your birth journey?
If you seek birth doula support, do you plan to utilize an epidural, or induce for due date, such as at 39, 40, 41 or 42 weeks?
If you are planning a hospital birth, have you ever considered a free-standing (not in-hospital) birth center birth, or home birth with midwives?
Anything else you'd like to share with Camille?
