Home
About
My Story
The Elements + Ayurveda
Work with me
Pregnancy, Birth + Postpartum
Ayurvedic Chef + Meal Plans
Holistic Support Programs
Online Classes
Mentorships
Journal
Notes On Birth
Mary's ♡ Recipes
All Things Ayurveda
Events
Contact
MARY A WHITLOCK
Home
About
My Story
The Elements + Ayurveda
Work with me
Pregnancy, Birth + Postpartum
Ayurvedic Chef + Meal Plans
Holistic Support Programs
Online Classes
Mentorships
Journal
Notes On Birth
Mary's ♡ Recipes
All Things Ayurveda
Events
Contact
MARY A WHITLOCK
Nurture + Nourish + Ayurveda
Learn More
Hello,
Please fill out the following Virtual Doula Client Intake, Confidentiality + Liability Release, in preparation for your initial session.
If you have any questions about any of the fields, please send me an email: mary@maryawhitlock.com, or we can go over them when we meet.
Thank you for your time. I look forward to working with you!
Warmly,
Mary
CLIENT INTAKE
Name
*
First Name
Last Name
Email
*
What is your phone number?
Address
*
Please note your current mailing address below.
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Where did you grow up?
What is your Birthday?
MM
DD
YYYY
What is your EDD?
MM
DD
YYYY
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?
Is this your first pregnancy?
If not, how many previous pregnancies have you had?
How has your digestion lately? Do you frequently experience, constipation, gas, or loose movements? Or are you pretty regular?
How many children do you have?
What is your current relationship status?
What's your current occupation?
Do you have any therapies, alternative healers + helpers with which you are recently involved?
What role does exercise play in your life?
How is your sleep? On average, how many hours do you get per night??
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)
Do you have any allergies? If so what?
Do you have a meditation practice? If so how frequently do you you meditate?
Have you had any serious illnesses/ hospitalizations and or injuries ? If so what?
Do you currently have any pain, stiffness or swelling?
Are you currently taking any medication, supplements or prenatal vitamins?
Do you like to cook?
What percent of your food is home cooked?
How is your digestion? Do you frequently experience, constipation, gas, or loss movements?
What’s your regular diet like (breakfast, lunch and dinner)? do you have any dietary preferences?
Is there any food that you currently aren't eating or just DON'T like? If so what?
Any additional comments?
CONFIDENTIALITY + LIABILITY RELEASE
CONFIDENTIALITY I hereby acknowledge and agree to allow Doula, and Health Coach, Mary A. Whitlock to take notes about me, including personal information I choose to disclose to her and information regarding my health, pregnancy, birth, and postpartum, as well as any other family information. 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: * According to this Agreement, services of the trimester doula package will be virtual. *The role of Mary A. Whitlock is limited to the services outlined in her trimester virtual doula support package. * 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. * I assume the risks of this service, including the risks of trying new foods or supplements and the risks inherent in making lifestyle changes.
If the terms of this Agreement are acceptable, please sign the acceptance in Steps 1 + 2 below .
Step 1
*
Check the box * By checking this box and typing my name below, I am electronically signing the client waiver, and I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.
Step 2
*
Type in your name First and Last, as your signature for acknowledgment of the above client waiver
First Name
Last Name
Thank you!
Name
*
First Name
Last Name
Email
*
Subject
*
Message
*
Thank you!
