WELCOME

I'm honored that you've chosen me to support you during this beautiful journey.

STEP 1. FILL OUT THE
NEW CLIENT CONTRACT / INTAKE FORM
(below)

STEP 2. MAKE THE INITIAL PAYMENT
(next page)

Once both of these are received your spot on my calendar will be secure.

Blessings,

- Nikki

Step 1. Fill out the Form

Client Intake Form + Contract Waiver

This digital form serves as your official Client Intake and Contract with Nikki Yerke, Birth Doula.

By completing and signing this form, you acknowledge that you have received, read, and agree to the Scope of Services outlined in the Doula Welcome Guide and understand the terms of care described within. This form is legally binding and replaces the need for separate printed contracts and media releases.

Please read each section carefully and take your time to respond. Your responses help me support you with clarity, alignment, and respect throughout your birth journey. Thank you! - Nikki

Please select one

New Client

Returning Client

First name

Last name

Phone

Home Address

Birthday

Month

Day

Year

Current Age:

If your partner is involved, what is their name? (if not, N/A)

Estimated Due Date:

What baby # is this?

Tell me about your pregnancy and previous births (if applicable)

Where do you plan on birthing?

Hospital

Home

Birth Center

Undecided

Location Name / City of where you plan to give birth

Please list all of your medical conditions. Do you have any previous surgeries or injuries? Relevant medical conditions? Currently any pain?*

What is your viewpoint on due dates?

They are very accurate and should be closely followed.

They are an estimation & I know babies come when they come.

I am somewhere in the middle.

Unsure or undecided

Do you have a birth plan?

Yes! It's all set and finalized

I have an idea of what I want, but I'm still revising

No and don't want one / don't want help (I'll go with the flow)

No, and I would like help or guidance

How much do you believe your care team should be involved with decision making at your birth? Please select the one that feels most aligned for you. There is no right or wrong answer.

Minimal involvement — I prefer to make my own decisions and lead the process. (I value guidance, but I want to stay informed and involved in every decision.)

Collaborative — shared decision-making with open communication. (I want to be informed, but I’m comfortable letting my care team take the lead if needed.)

High involvement — I prefer my provider to make decisions in real time. (I feel safest when my care team takes charge during the birth process.)

Not sure yet — I’m still exploring my preferences. (And that’s totally okay.)

What is your view on pain management?

I want to explore natural pain relief first (movement, breathwork, water, etc.), and only consider medical options if needed.

I plan to or am open to using medical pain relief (such as an epidural or medication) and want support around that choice.

I believe in full autonomy and making decisions in the moment, based on how I feel.

I want to avoid medical pain relief entirely and focus on natural comfort measures only.

Undecided; would like guidance

Any complications in previous pregnancies? (i.e. hyperemesis, high risk, high blood pressure, etc. Please explain) None: N/A

Any complications in THIS pregnancy? (i.e. hyperemesis, high risk, high blood pressure, etc. Please explain) None: N/A

Do you have any cultural or religious considerations? If yes, please explain:

What sports have you played in the past? Any current?

What do you do for work?

What do you do for fun?

What fears or concerns do you have about pregnancy, birth, or postpartum (if any?)

I would love to hear why you would prefer a certain birth location; this will help me best understand you and your perspective!

Tell me about your desires & goals for your upcoming birth: is there anything you are looking for in the experience? Anything you are looking to avoid?

What (if anything) do you think would be the most foreseeable challenge for this pregnancy / birth / postpartum?

Do you have any food allergies? If so please list them here. None: N/A

I consent to Nikki documenting parts of my birth experience (notes, non-identifying details) for recordkeeping and training purposes

I give permission for my birth story to be shared for educational, social, or promotional purposes. (optional)

I give permission for my birth photos / videos to be shared for educational, social, or promotional purposes (i.e., would it be okay to post birth photos to social media?) (optional)

*IF you gave consent for your birth story or photos / video to be shared . . . please select your preference for sharing your name:

I prefer to remain anonymous

You may use my first name only (do not tag me in the posts)

You may use my full name and / or tag me in the posts

Payment Deposit:

Preferred method of deposit: Venmo @NikkiYerke or Paypal @NikkiYerke (last four digits of phone: 2552).

Or for your conveneince, you can use pay link by selecting the package you have chosen and the corresponding deposit.

If you want to pay via cash / check please check box to request invoice.

Thank you :)

Please invoice me separately. I prefer manual, cash or check payment options

By signing & submitting this form, I confirm that:

I have received, read, and agree to the Scope of Services outlined in the Doula Welcome Guide provided by Nikki Yerke, Birth Doula.
I understand that this electronic agreement, along with the selections made above regarding documentation and media permissions, constitutes our service agreement and electronic consent.
I understand that the non-refundable deposit is required to secure services
I agree to the client terms, boundaries, and communication guidelines outlined by Nikki Yerke.
I understand that by typing my name below, I am signing this document electronically and affirming my acceptance of the terms above.

Yes, I understand and agree

Signature

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Once you have submitted this, please check your email for your
New Client Welcome Guide

WELCOME

Step 1. Fill out the Form

Client Intake Form + Contract Waiver

Payment Deposit:

By signing & submitting this form, I confirm that:

"You were never meant to do this alone."