Let’s work together Birthing Person's Name * First Name Last Name Partner/Support Person's Name: * First Name Last Name Birthing Person's Email * Partner/Support Person's # (###) ### #### Birthing Person Phone # (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Due Date MM DD YYYY Siblings Names & Ages (if applicable): Hospital/ Birth Center Midwife / OB Pediatrician How long do you anticipate needing Postpartum doula support? What are your main reasons for choosing to use a Postpartum Doula? Infant Care Guidance Breastfeeding Support Maternal Postpartum Recovery Emotional Support Household Maintenance Meal Preperation Help With Siblings If you had any complications during your pregnancy or pre existing health conditions, please describe: Do you have any cultural or religious belief you would like me to be aware of that might affect my care for your family? How will your baby be fed? Do you or your family have any dietary preferences, restrictions, or food allergies you would like me to be aware of? If you or your partner work, do you plan on returning to work, and when? Is there anything else you would like me to know about you, your baby or your family? Thank you so much! I will get back to you as soon as I can.
