MARY A WHITLOCK

Nurture + Nourish + Ayurveda

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Hello,

Please fill out the following doula client intake + release form in preparation for our meeting.

If you have any questions about any of the fields, leave them empty and we can go over them when we meet.

Thank you for your time. I look forward to meeting with you!

Kindly,

Mary

Name

First Name

Last Name

Phone

(###)

###

####

Address

Current

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What's your birthdate?

YYYY

What's your occupation?

Support Person or Partners Name

First Name

Last Name

What's your EDD?

How many previous pregnancies have you had?

Have you decided on your birth place + practice? If so , what Hospital, OB or Midwifery practice are you with?

Have you taken or are you enrolled in a Childbirth Ed course? If yes, which one?

How has your energy level been lately? (on a scale from 1-10 --10 being a lot of energy, 1 being the lowest amount of energy)

How is your sleep? How many hours?

How is your digestions? Do you frequently experience, constipation, gas, or loose movements?

Do you currently have any pain, stiffness or swelling?

What role does exercise currently play in your life?

Any therapies, bodywork, alternative healers + helpers with which you are involved?

Have you had any serious illnesses/ hospitalizations and or injuries? If so what?

Do you take any supplements or medications? If so what?

Do you have any recent dietary cravings? If so what ?

Do you have any recent dietary aversions? If so what?

Is there anything else that you would like to share?

CONFIDENTIALITY + LIABILITY RELEASE

CONFIDENTIALITY I understand that my client information and any notes, images, and or videos are confidential and can only be used with my consent. RELEASE FROM LIABILITY I hereby acknowledge and agree that: * Mary A. Whitlock has not represented to me that using her services guarantees in any way a risk-free or emergency-free labor and birth experience. * I am fully responsible for my diet, healthcare, life, and wellbeing decisions for myself and my family. * Mary A. Whitlock will not be held liable for any consequence to my family or me, resulting from decisions I make. * Mary A. Whitlock does not make medical decisions on my behalf.

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by checking this box, I agree to the confidentiality and liability release terms as listed above

What’s your unique elemental constitution?

Find out below in my FREE ayurvedic dosha quiz

Free dosha quiz

Hello,

Please fill out the following doula client intake + release form in preparation for our meeting.

If you have any questions about any of the fields, leave them empty and we can go over them when we meet.

Thank you for your time. I look forward to meeting with you!

Kindly,

Mary

What’s your unique elemental constitution?

Find out below in my FREE ayurvedic dosha quiz

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