Personal Information

Thank you for choosing Christine as your doula! This form is designed to help us understand your needs, preferences, and expectations as we work together to support you during this transformative time. By completing this form, you provide essential information that helps us create a personalized and meaningful experience for your pregnancy, labor, and postpartum journey.

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

When is your expected due date?

Emergency Contact Name

Relationship

Emergency Contact Phone

What hospital or location are you planning to deliver your baby?

Why a Doula

What made you choose doula services?

What inspired you to choose Christine Stancle to be your doula?

What expectations do you have of Christine as your doula?

Payment Information

Do you have Medicaid?

Yes

No

If "Yes", what type of Medicaid do you have?

If “Yes”, Medicaid covers up to 12: prenatal and postpartum. Please indicate how you would prefer those 12 appointments be divided?

Medicaid Insurance ID Number

Medicaid Insurance Group Number

Number of desired prenatal support visits

Number of desired postpartum support visits

I’d like help deciding how to use to divide these appointments.

If “No” Medicaid what will be your payment method?

Multi choice (select all that apply)

Personal Finance (out-of-pocket)

Bartering (please specify below)

If bartering, please indicate services offered in exchange for doula services. **Subject to Christine’s approval.

Where do you feel you would benefit from the most support?

Prenatal Care

Labor & Delivery

Postpartum Care

Labor & Delivery Preferences

When would you like labor & delivery support to begin?

I want Christine with me as much as possible.

I would like Christine with me once I arrive at the hospital.

I want Christine to be with me once I begin active labor.

I would like Christine to be with me only after the baby has arrived.

Other

What forms of comfort measures are you interested in during labor? (Selected all that apply)

Hands-on physical comfort (e.g. hands, back neck massages)

Help with modifying positions for comfort or labor progression.

I would prefer that my partner or other support person do the comfort measures with me.

I need help deciding.

Other

Additional Support

Would you like lactation support?

Yes

No

Unsure

Agreement

By electronically signing this contract, I acknowledge and agree to the following:

I understand the scope of practice of a certified doula and that while skilled in birth and lactation support, Christine is not a physician.

I understand my privacy rights under HIPAA and consent to the use of my personal information as described above.

I agree to the terms of payment and services outlined in this contract.

Signature

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