Your name
*
First Name
Last Name
Your preferred pronouns:
Your email
*
Your phone number
*
(###)
###
####
Do you have a preferred method of contact?
Other:
Do you have any core identities, or anything else that you would like to share with me?
Partner/Support persons name
First Name
Last Name
Partner/Support persons preferred pronouns:
Partner/Support persons phone number
(###)
###
####
Your estimated due date
MM
DD
YYYY
Birthing location
Birthing location address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Do/did you have a primary caregiver chosen for your birth?
Have you been postpartum before (including any losses that you consider postpartum)?
What about those experiences would you like to be the same or different this time?
What are you most excited about for this postpartum? And (if applicable) support person(s)?
Do you have any fears or concerns about the postpartum time or newborn care?
Is there anything in your personal history that might make it hard for you to cope with the experience of postpartum?
Do you have any medical conditions that you feel may affect your postpartum period? If so, please share as much as you are comfortable.
Have you/did you experience any pregnancy complications?
Do you have any spiritual or religious practices that you would like to include in your postpartum care? If so, do you need my assistance with any of this?
What is your current or planned method of infant feeding? (nursing, pumping, formula, etc)
What can I do to best support this plan? (lactation resources, walk you through how to use your pump, be ready to support you if your plan changes, etc.)
Would you like to create/modify a postpartum plan? (meal train, go-to people to call or check in with, etc). If so, what sort of things would you like to include in your postpartum plan?
Do you have any concerns about your ability to feed your baby?
Do you feel that you have a supportive community in the area? If not, what can I do to help you feel supported?
What are your expectations of me as your postpartum doula?
Do you have any allergies (Food, medication, etc) or food preferences?
Postpartum Support Team (for you):
Postpartum Support Team (for your baby)
Do you want any additional information on the following?
Other:
Please share anything else you would like me to know about you or any topics you would like to discuss
