New England Placenta Encapsulation

Placenta Encapsulation Services serving Boston, North Shore, South Shore, New Hampshire, & Rhode Island

New England-based Placenta Encapsulation, Doula Support, and Postpartum Care serving Boston, North Shore, South Shore, New Hampshire & Rhode Island 

Client Intake Form 

If you will be using me as your doula, please take some time to fill out and submit the client information form below prior to our first prenatal visit. This information is kept secure & confidential. We will have the opportunity to go over the information you've provided at our visit.

If you find a question does not apply to you, please answer with N/A; if you find that you don't have an answer for the more introspective questions, please consider allowing yourself to sit with the question to see if anything comes up. Those responses allow me to better understand what your needs & wants are in your birth experience & how I can help you achieve that. 

Contract (including Payment, Cancellation and Refund Policies) *
I have read and agree to the terms and conditions as set out in the Letter of Agreement describing the Doula Services provided by Jennifer Lynn Frye. (If you have any concerns or questions about the terms outlined in the contract, please contact me before agreeing.)
Name *
Name
Partner's Name (if applicable)
Partner's Name (if applicable)
Birthing Individual's Date of Birth *
Birthing Individual's Date of Birth
Estimated Due Date *
Estimated Due Date
Phone *
Phone
Additional Phone (if applicable)
Additional Phone (if applicable)
Home Address *
Home Address
Please include any special instructions, such as buzzer number, parking tips or details about how to get to your home if you feel it may be helpful.
Is this your first pregnancy? *
Are you taking prenatal education classes? *
i.e. Hospital, Birth Center, Home birth- If Hospital, please specify which facility & whether you have registered/toured.
Accupuncture, TCM, Chiropractor, etc
Health History
To your knowledge, do you have or have you had any of the following:
Childbirth History
Please complete this section if Applicable. If not, leave blank.
i.e. abortion, miscarriage, infertility, stillbirth or children placed for adoption
gender, weight, birthdate, name
Vaginal or Cesarean? How did your labor begin? How long did it last? How did you push? What coping techniques did you use? Did you breastfeed/formula feed/both?
Complications with the birth itself, immediate health of baby/you, with breastfeeding, etc.
Upcoming Birth
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.
Would you like any recommendations?
Additionally, is there anyone you do not want present at this birth?
Do you want or have you written a birth vision/plan? *
Baby Talk
i.e. Immediate skin-to-skin, delay newborn procedures if possible, allow to nurse immediately, etc.
Are you interested in delayed cord clamping?
Do you plan on breastfeeding? *
Do you need any additional resources?
If your child is male, are you planning on circumcision? *
In regards to newborn procedures, please check the boxes below that apply to you.
Check those that you plan on getting and any other boxes that apply to you
Doula/Client Logistics
Unlimited phone, email, & text come with my service to you, in addition to our face to face meetings.
All 3 are available, but which do you prefer?
i.e. right when labor starts, at home, at the hospital, in active labor, etc.
Many women prefer to labor at home as long as possible, but it's a matter of what you're comfortable with.
Please mark any items that you would like to discuss during our visits
This allows me to prepare accordingly & provide you with the best information.