Question Title

* 1. Name

Question Title

* 2. Email Address

Question Title

* 3. Phone Number

Question Title

* 4. What is your preferred way of contact?

Question Title

* 5. What are 3 of your goals and aspirations for your birthing experience?

Question Title

* 6. Have you previously worked with a doula or received birthing support services?

Question Title

* 7. What aspects of your previous birthing experience, if any, would you like to replicate or improve?

Question Title

* 8. List 3 things that you think are/will prevent you from achieving the goals listed in the prior question.

Question Title

* 9. Please identify any strategies that you are doing now to move you closer to achieving your goals?

Question Title

* 10. How do you rate your current support system that you have in place for your birthing journey?

  1. Extremely satisfied, comfortable and do not want any additional growth
  2. Satisfied but have thoughts to explore other opportunities for growth
  3. Not satisfied but excited and ready for change
  4. Simply frustrated and dont know what to do

Question Title

* 11. What specific support are you seeking from a doula during your birthing journey?

Question Title

* 12. Please list any specific cultural or spiritual considerations important to you during this time?

Question Title

* 13. Are there any specific fears or concerns you have about the birthing process that you would like support with?