Your Name
*
First Name
Last Name
Your pronouns
*
Your date of birth
*
MM
DD
YYYY
Phone
*
(###)
###
####
Email
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
How did you hear about me?
*
Your Partner/Support Person's Name (IF applicable)
First Name
Last Name
Your Partner/Support Person's Pronouns (IF applicable)
Your Partner/Support Person's Phone (IF applicable)
(###)
###
####
Your Partner/Support Person's Email (IF applicable)
Any other parents/Support Person(s) in this journey to be included?
*
If you are absolutely riding this journey solo, don't worry, I got you! Just put n/a.
Emergency Contact
*
If you listed a partner/support person, please include one more person as an emergency contact!
First Name
Last Name
Emergency Contact's Phone
*
(###)
###
####
Baby's Expected Date of Arrival (Due date, adoption date, etc.)
*
MM
DD
YYYY
Will you be having multiples? If yes, how many?
*
Baby's Gender(s) & Name(s) if known
Who do you share your home with?
*
Where are you planning to give birth?
*
What appeals to you most about having a postpartum doula? (Check all that apply)
*
Tell me about your journey to parenthood. Whether through pregnancy, adoption, surrogacy, etc., I'd like to know!
*
If you've struggled with pregnancy losses, infertility, etc., and are comfortable sharing, I'm here to listen. There is absolutely no obligation to disclose any of this information.
What are your top two priorities for the postpartum period?
*
If you're having a boy: are you planning on circumcising him?
*
YES
NO
N/A
Is this your first child(ren)?
*
If it's not your first child(ren), tell me about the other(s)!
If you're comfortable sharing: does your family include step children/blended family, adopted children, etc.
Do you have a pediatrician? If yes, who? If no, do you need help finding one?
*
Do you have any pets in the home? If yes, what kind and what is/are their name(s)?
*
P.S. I love animals.
Do you have any cultural or religious beliefs you would like me to be aware of that might affect my care for your family?
*
Tell me about your plans/goals for feeding your baby (breastfeeding, formula feeding, combination of both, pumping/bottle feeding expressed breastmilk):
*
Do you or your family have any dietary preferences, restrictions, or food allergies you would like me to be aware of?
*
Ex. If you're napping, and I make a snack for another little of yours, are there allergies I should be aware of?
What are some of your favorite foods, snacks, drinks, etc. or are there any recipes you'd like to share with me?
*
If you work, do you plan on returning to work, and when? How about your partner (if applicable)?
*
Please also include what you (and your partner, if applicable) do/did for work.
Does anyone smoke in the home?
*
Do/Did you have any pregnancy conditions? (gestational diabetes, high blood pressure, preeclampsia, etc.)
*
Are there any medical concerns/issues you'd like to share? Whether for yourself, your partner, your children, etc.
*
Please also include any mental health issues for yourself or members of your family. This period is a major emotional adjustment; so, it's important to know if there's a history to be aware of.
Do you have any concerns/fears about your postpartum period?
*
Is there anything else you would like me to know about you, your baby or your family?
*
