Postpartum Doula Intake Form

Caring for You — Body, Heart, and Home

First name

Last name

Email

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Are you taking time off of work

Yes

No

Undecided

If yes, when will you return?

Estimated Due Date or Baby's Birthdate*

Hospital/Birth Center

Gender(s) if known:

Pediatrician's Name

Midwife or OB/GYN Name

If you had any complications during your pregnancy or pre existing health conditions, please describe:

How long do you anticipate needing Postpartum doula support?

What are your main reasons for choosing to use a Postpartum Doula? Check all that apply.

Do you know if you will want doula services for daytime, nighttime, or a combination of both?

Day time

Night time

Both

How will your baby be fed? (breastfeeding, formula feeding, combination of both, pumping/bottle feeding expressed breast milk):

Do you or your family have any dietary preferences, restrictions, or food allergies you would like me to be aware of?

Do you have any cultural or religious belief you would like me to be aware of that might affect my care for your family?

Have you and your partner taken any education in preparation for your postpartum period? (Childbirth preparation, breastfeeding, newborn care, infant CPR, etc.):

Is there anything else you would like me to know about you, your baby or your family?