Junie

Client intake form

Copy this into your own document or print it, then remove every question your practice does not need. The template includes pregnancy, loss, health, and wellbeing prompts, which may be sensitive consumer health data even when the doula is not a medical provider.

Before collecting responses, tell clients why you need them, where they are stored, who can see them, how long you keep them, and how to request a correction or deletion. Ask a qualified advisor which privacy rules apply to your practice.

Getting to know you — [your business name]

I use these answers to prepare the support described in our agreement. Questions marked optional may be skipped or discussed in person. My privacy notice explains how I store, share, retain, and delete this information: [link or contact].

You and your family

  • Your name, pronouns, and how you like to be addressed
  • Partner/support person's name and pronouns (if any), and the role they hope to play
  • Best phone and email; preferred way to reach you (call / text / email)
  • Address (for home visits)
  • Other children or household members I should know about (names/ages)
  • Emergency contact (name, relationship, phone)

This pregnancy

  • Estimated due date
  • Where you plan to give birth (hospital / birth center / home) and its name
  • Your care provider (OB / midwife / family practice) and practice name
  • Is this your first pregnancy? If not: prior births (how many, and anything about them you want me to know), and any losses you'd like me to hold with care (optional, share only what you wish)
  • Anything about this pregnancy your care team is watching (in your own words, I don't need medical records)

Support and preferences

  • What drew you to doula support? What does great support look like for you?
  • Hopes for this birth, and any worries you want me to know about
  • Comfort measures you're drawn to (movement, touch/massage, water, breathing, quiet, music…) and any you dislike
  • Cultural, religious, or spiritual practices you'd like honored in your care
  • Language preferences; anything about your body, history, or boundaries that affects how you'd like to be touched or spoken to
  • How involved would you like your partner/support person to be, and how can I best support them?

Wellbeing (optional, in your own words)

  • How are you doing emotionally in this season? Anything about your mental or emotional health (past or present) that you'd like me to know so I can support you well?
  • Note: I'm not a therapist or medical provider. If you're struggling, I'll always encourage and help you connect with professional support.

Feeding and after the birth

  • Current feeding intentions (nursing / pumping / formula / combination / deciding), all are supported here
  • Postpartum plans: who's around in the first weeks? What support do you expect to have, and where do you already suspect you'll want more?

Logistics

  • Anything else you want me to know?
  • How did you find me? (helps my small business, thank you!)

Junie does not yet collect or store this questionnaire as an in-product intake flow. If you use the template elsewhere, choose a storage and delivery method appropriate for the sensitive information you ask clients to share. See the current Junie product fact sheet or return to all templates.