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Barefooted Beginnings

New Client Intake Form

First and foremost, congratulations! Thank you so much for reaching out and considering me to be your doula during this exciting time. It is a blessing and honor for me. Before our journey together, I like to make sure we are a great match. I want you to feel 100% confident and comfortable with your whole birth team. Please fill out the questionnaire below to get a little more information before setting up a consultation call.

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Chat soon!

Melina Laverde

Let’s Connect!

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Greater Houston Area
(Serving Houston and surrounding areas)

Intake Form

Birthday
Month
Day
Year

Pregnancy:

Estimated Due Date
Month
Day
Year

Pregnancy History:

Have you given birth before
Yes
No
History of infant loss or miscarriage?
Yes
No
I am a Christian doula, however, I do not and will not push my beliefs onto my clients. I support all ethnicities, races, cultures and traditions. Is that okay with you?
Yes
No

Once I have received your intake form, I will be contacting you if I am available or not. If I am, we will schedule a free 45 min consultation video call to go over your form and any other questions we may have.


Have a blessed day!

Meli

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