Postpartum Doula Intake Form

All your information will be kept strictly confidential!

All starred fields are required. If a non starred field is not applicable, feel free to leave it blank.

If the form will not submit (you do not see a Thank You message) it is because you are missing a required field. Please scroll back up and you will see the required field highlighted.

Pregnant Persons Name

*Choose your pronouns. *Choose your pronouns. she/her he/him they/them other

Partners Name

*Your partners pronouns. *Your partners pronouns. he/him she/her they/them other

*Your phone number with area code.

Partners phone number with area code.

Enter your email address.

Include your partners email if they would like to be CCed in all our emails.

*Home Adddress- Include City and Zip Code

Any special driving or parking directions?

*Estimated due date or if baby is already here, birth date.

*Gender of baby.

*Location you plan to deliver.

*Name of careprovider and if applicable their group name.

What are the names and ages of other children I might interact with?

What are the interests of your older children, whom I may be interacting with?

Please list any pets that I might interact with.

Do you have any religous and/or spiritual affiliation or special customs that I should know about?

*I confirm that I do not use artificial air fresheners, sprays or candles in my home.

*List any classes, books, videos and websites you have engaged about baby care, breastfeeding and parenting.

What other classes are you taking or plan to take?

List any medical, food or environmental allergies and sensitivies you have.

List any medical, food or environmental allergies and sensitivies anyone living with you have.

If you want me to cook- What are your preferred cooking styles and food preferances?

*How much time are you taking off of work?

*How much time is your partner taking off of work?

*Does anyone in your home smoke, drink alcohol regularly, or take illegal drugs? If yes, please explain.

*Do you have any fire arms stored outside of a locked safe in your home? *Do you have any fire arms stored outside of a locked safe in your home? yes no

*Check off any of the following mood disorders you have been diagnosed with now or in the past. *Check off any of the following mood disorders you have been diagnosed with now or in the past. Depression Anxiety OCD Bipolar Other None

List any other medical, physical or mental issues you think I should know about.

List any other medical, physical or mental issues in your home members you think I should know about.

*Check off any of the following breast procedures or diagnosis that apply. *Check off any of the following breast procedures or diagnosis that apply. Breast reduction/augmentation. Breast surgery of any kind. Pierced nipples. IGT/Hypoplasia Flat or inverted nipples. Other None

*Have your breasts changed during pregnancy? *Have your breasts changed during pregnancy? yes no I don't know.

*Please check off any and all topics or tasks you think you might want help with. *Please check off any and all topics or tasks you think you might want help with. parenting/ early child development running errands/ grocery shopping cooking dishes/ kitchen clean up laundry vacuuming/ sweeping trash/ recycling dusting organizing closets picking up after older children pet care- feeding, walking, washing watching child(ren) while you sleep playing with older siblings breastfeeding pumping bottlefeeding burping bathing cord care diapering swaddling holding and passing baby dressing crying infant sleep baby wearing car seat safety

Is there anything not included on the check list that you would like to add?

*What is your top reasons for wanting a postpartum doula?

Is there anything else you would like for me to know or any questions or topics you would like covered?

6 + 7 =

Heather Ward BD, PD, CCE, CLE

Postpartum Doula Intake Form