Doula Preferences Form

Please fill out this form carefully. Leave blank any technical terms or questions with which you are not familiar, or any questions you prefer not to answer, or to answer in person. The more information you can provide the better.

• Name *
  First Name Last Name

• How can I best serve you as your doula?

• Physical Help (when/if needed)
  Ensure you have food/drink on hand Physical comfort (eg. ensure you're not too hot/cold, have enough pillow/blankets, the lights are dim, the room is quiet etc.) Massage Acupressure Sacrum counter-pressure Rhythmic movement Help moving positions Breathing techniques Application of heat/cold Help operating TENS (I have the Elle TENS for hire)
• Are there other ways you would like me to help you physically?
• Emotional Support (when/if needed)
  Continuous presence Maintain a positive and peaceful environment Provide plentiful encouragement and praise Advocate your birthing preferences Guided meditation / visualization / focal points
• Are there other ways you would like me to help you emotionally?
• Informational Support (when/if needed)
  Information about the risks/benefits of interventions Information about natural pain relief techniques Information about specific topics (list them below) Help creating your birth preferences Recommended books/websites/studies
• Are there other ways you would like me to help provide information?
• Other Support (when/if needed)
  Ensure your partner/loved one's are informed and take care of Show your partner/loved one's ways they can support you Take photo's/video of the birth Ensure placenta is saved
• Are there other ways you would like me to help provide support?
• Should be Empty: