Integrative Postpartum Doula Support Intake Form

Doula For The People Integrative Postpartum Doula Support Intake Form
Doula For The People (DFTP) exists to expand access to liberatory, trauma-informed postpartum care for individuals and families who have been historically and systematically underserved by traditional healthcare systems. Our work is rooted in the belief that postpartum care is not a luxury. It is a collective responsibility, a public health necessity, and a vital part of reproductive justice.

Through our Integrative Postpartum Doula Program, we offer more than postpartum doula services alone. Our care model weaves together evidence-based practices and holistic, embodied approaches to support the whole person physically, emotionally, spiritually, and relationally during the postpartum period. We honor that healing and care are not one-size-fits-all, and we center your lived experience, values, culture, and needs throughout this process.

Participants in this program receive:
- 32 hours of no-cost postpartum doula care
- Six weeks of Foodie Doula meal deliveries thoughtfully designed to nourish and support postpartum recovery
- An opportunity to join one of our Postpartum Sanctuary Circles, which are community-based spaces for collective care, reflection, and connection
Qualifying Requirements:
- Must live in Contra Costa, San Francisco or Alameda County
- These services center BIPOC Identifying postpartum people
This intake form helps us get to know you and your needs so we can thoughtfully match you with doulas who feel aligned and supportive. After you submit this form, you will be connected with our Program Manager, who will review your responses and identify three doulas we believe may be a good fit. You will receive their bios and headshots and be invited to let us know which doulas you would like to move forward with.

From there, the selected doulas will reach out to you directly to schedule an initial consultations, assess your needs, and create your care plan.

We are honored to walk alongside you during this tender and powerful season. Thank you for trusting us with your care.
General Information
Full name of the person requesting services*

First NameLast Name
What are your pronouns (He/Him, She/Her, They Them)?*
Email Address*
example@example.com
Client phone number*
Please enter a valid phone number.Format: (000) 000-0000.
Physical Address including city and zipcode (where you'll be receiving services and or receiving meal deliveries and postpartum wellness care packages)*
Do you have any food allergies?*
When Are you hoping to receive doula support?*

MonthDayYear
Date
Are you a minor?*

YesNo
How were you connected to these services?*

Doula For The PeopleUCSF Mt.Zion Womens ClinicSan Francisco General HospitalBlack Women Birthing JusticeBlack Girls Mental Health FoundationSister WedCoco DoulasInstagramCommunity flyerOther Community Partner
How do you racially Identify?

Black/ African AmericanAfrican / African DiasporaLatine / Hispanic / ChicanxIndigenous / Native American / Alaska NativeNative Hawaiian / Pacific IslanderAsianMiddle Eastern / North African (MENA)WhiteMultiracial / MixedPrefer not to answer
Are you Interested in in-person or virtual doula support?*

In-personVirtual
What type of postpartum doula services are you most interested in receiving?*

Emotional supportLactation supportMeditation and groundingMeal PrepClosing of the bones ceremonyProcessing of your story- and ear to listen and hold spaceSupport implementing mindfulness practices (affirmations, journal prompts, ritual/habit tracking)Sacred sleep guidance and reclaiming restFundamentals of infant care- information around early childhood developmentSupport with light tidying around the house
Which postpartum care package feels most aligned for you?*

32 hours of doula support26 hours of doula support + access to up to $350 in additional postpartum wellness services
If selected additional services, which additional services would you like to receive as part of this care package?(Many of the doulas in our collective specialize in other holistic wellness modalities- being matched with a practitioner who specializes in an area you're interested in is not guaranteed, but we will try.)*

Death or greif supportAyurveda and AbayangaReikiMassageYogaHerbal supportNutritional supportFundamentals of infant careLactation support
If selected additional services, which additional services would you like to receive as part of this care package?(Many of the doulas in our collective specialize in other holistic wellness modalities- being matched with a practitioner who specializes in an area you're interested in is not guaranteed, but we will try.)

Ayurveda and AbayangaMassageReikiHerbalism ServicesLactation SupportPostpartum Closing CeremonyPelvic Floor Support
Doula Matching Questions
Why is having a doula important to you?*
What qualities are most important to you in a doula?*

KindDirectEmpatheticSpiritualGentleWarmFunnyLaid backInformativeWiseMotherlyFirmInstructiveHands on
If your best friends could describe you with 3 words which 3 words would it be and why?*
What doulas in our collective are you most interested in being matched with? Your preference will be taken into consideration, but it's not guaranteed because of the nature of doula work. (link to doula headshots and bios https://doulaforthepeople.org/dftp-collective)

Alaina LeeBashari GeorgeBriana WellsBrianna TrejucoBriana Kikamoto FujiChay TadeoDesola AmosJoanna TurnerJaontra HendersonKyrsha PryorTiffany WashingtomTeyler WallaceShivani NarangNo Preference
Program Overview, Scope of Care, Service Agreement:

Purpose of Services
The Doula For The People Integrative Postpartum Doula Program provides non-medical, holistic postpartum support to individuals and families during the weeks following birth. Services are designed to support physical recovery, emotional wellbeing, infant care, and family adjustment through a liberation-focused, trauma-informed, and culturally responsive care model.

Postpartum doulas affiliated with Doula For The People provide care that centers the whole person and honors each family’s unique needs, values, identities, and lived experiences.

Scope of Postpartum Doula Support
Postpartum doulas provide non-medical physical, emotional, and educational support during the postpartum period. Services may include, but are not limited to, the following:
- Emotional support and compassionate presence during the postpartum transition
- Education related to postpartum recovery, self-care, and adjustment
  Infant care education and hands-on support, including soothing, feeding support, and sleep education
- Lactation and feeding education, including chestfeeding, breastfeeding, bottle feeding, and combination feeding support
- Support with postpartum comfort measures and recovery practices
- Guidance in developing parenting values and caregiving routines
- Light practical support related to infant care, such as baby-related dishes or laundry, when appropriate
- Referrals to healthcare providers or community resources when additional or specialized care is needed
The specific focus of each visit is determined collaboratively based on the priorities and needs identified by the client and doula. Postpartum doulas do not provide medical care, diagnose conditions, or replace licensed medical providers.

Major housekeeping tasks are not within the scope of postpartum doula services.

Integrative Postpartum Doula Program Services
Participants enrolled in the Doula For The People Integrative Postpartum Doula Program receive the following services at no cost:
- 32 hours of postpartum doula care provided by a trained Doula For The People postpartum doula
- Six weeks of prepared meal support, designed to nourish postpartum recovery and support healing
- An opportunity to participate in a Postpartum Sanctuary Circle, a facilitated community-based space for collective care, reflection, and connection
  Participation in Sanctuary Circles is optional and subject to availability.
Health, Safety, and Medical Care
Postpartum doulas do not diagnose or treat medical conditions for either parent or infant. Doulas may share evidence-informed education and observations and will encourage clients to consult their pediatrician, midwife, obstetric provider, or primary care provider with any health concerns.

Clients are encouraged to seek medical care immediately if they have concerns about their own health or the health of their baby.

Health and Illness Communication
All parties agree to communicate promptly regarding illness or exposure to contagious conditions in order to support health and safety and make appropriate adjustments to services when needed, in alignment with current public health guidance.

Emergencies
In the event of a medical emergency involving an infant or parent, the doula will make reasonable efforts to contact the client and follow previously discussed emergency preferences. When necessary, emergency services may be contacted.

Client Responsibilities
Clients understand and agree that they remain solely responsible for their family’s wellbeing and medical decision-making.

Clients agree to:

Communicate their needs, priorities, and expectations clearly and honestly.
Notify their healthcare provider of any postpartum complications, and
Treat doulas with respect, care, and clear communication before, during, and after services. Provide a safe and accessible environment for postpartum support.

Surveillance Disclosure
Clients agree to disclose the presence of any cameras or surveillance equipment in the home prior to the start of postpartum doula services.

Limitation of Liability
Clients understand and agree that postpartum doula services provided through Doula For The People are non-medical and are intended to offer emotional, educational, and practical support only. Postpartum doulas do not diagnose, treat, or provide medical care and do not replace licensed medical providers.

To the fullest extent permitted by law, Doula For The People, its staff, contractors, volunteers, and affiliated postpartum doulas shall not be held liable for any injury, loss, or damage arising from or related to the postpartum doula services provided, except in cases of gross negligence or willful misconduct.

Clients acknowledge that they remain solely responsible for their own health and wellbeing and that of their infant(s), including all medical decisions. Any information or support provided by a doula should be considered complementary to, and not a substitute for, care provided by licensed healthcare professionals.

In no event shall Doula For The People or affiliated postpartum doulas be liable for incidental, indirect, special, consequential, or punitive damages arising out of participation in the Integrative Postpartum Doula Program, regardless of the theory of liability.

Nature of Agreement
This program description outlines the general scope of services provided through the Doula For The People Integrative Postpartum Doula Program. Specific scheduling, doula matching, and service details are coordinated through Doula For The People and participating postpartum doulas.
Client Signature*

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Doula For The People Integrative Postpartum Doula Support Intake Form

General Information

Doula Matching Questions