Client Intake | Chattams Rooted Care Collective

Step 1 of 8 · Tell us about you

Client Information

Full name

Preferred name

What would you like us to call you?

Date of birth

Phone

Email

Street address

City

State

ZIP

Preferred contact method

Phone callText messageEmail

Step 2 of 8 · Your pregnancy so far

Pregnancy Information

Estimated due date

OB / Midwife

Planned birth location

HospitalBirth centerHomeNot sure yet

Hospital or birth center name

Pregnancy number

Including this pregnancy (e.g. 1 for a first pregnancy)

Number of previous births

Pregnancy complications

Step 3 of 8 · So we can support you safely

Medical History

Share only what you’re comfortable with. Your doula provides non-medical support; this helps us understand your needs.

Allergies

Medications

Medical conditions

Mental health history

E.g. anxiety, depression or past postpartum mood changes. Optional.

Step 4 of 8 · Your people and your plan

Support Team & Birth Preferences

Step 5 of 8 · Social determinants of health

Everyday Needs & Resources

Things like housing, food, transportation and safety affect your health and your baby’s. These questions help us connect you with support. Every question is optional, and your answers won’t affect your care.

Step 6 of 8 · Payment policy

Package, Payment & Insurance

Payment method

Selected package

Seed Package$8502 prenatal visits · Labor & birth support · 1 postpartum visitBloom Package$1,2503 prenatal visits · Labor & birth support · 2 postpartum visits · Doula client welcome kitRooted Care Signature Package$1,750Everything in the Bloom Package · Lactation support · Extended postpartum care · Unlimited education & resource navigationNot sure yetWe’ll help you choose at your consultation

Insurance information (if using Medicaid or insurance)

Insurance company / plan

Member ID

Group number

Policy holder

Payment policy. I agree to the Chattams Rooted Care Collective payment policy.

Step 7 of 8 · Just in case

Emergency Contact

Primary emergency contact

Relationship

Phone

Step 8 of 8 · Almost done

Agreements & Signature

Doula agreement. I acknowledge that I have read and agree to the Chattams Rooted Care Collective Doula Services Agreement.

Informed consent. I understand my doula provides non-medical support only.

HIPAA acknowledgment. I acknowledge receipt of the HIPAA Privacy Notice.

Client rights & responsibilities. I have read and understand my rights and responsibilities.

Photography & media release

YesYes, without identifying informationNo

Typed name (electronic signature)

Date

By typing my name, I agree this serves as my electronic signature.

Welcome — let’s get to know you.