New Client

Mothers Name

Phone

Spouse/Partner Name

Phone

Preferred Contact

Phone call Text Email

Mailing Address

Mother Occupation

Father Occupation

Postpartum Care Package You’re Interested In

Introductory Standard Premium Deluxe

All About You

Are you taking time off from work and if yes, how long?

Will your spouse/partner be taking time off from work and if so, how long?

Do you have any adults living in your home and if so, who are they and what are their ages?

If you have other children, what are their names and age?

If you have other children, how do they feel about the new baby?

Are there any pets in your home and if so, what kind and what are their names?

Medical Information/History

Pediatrician name

Pediatrician phone

Midwife/Ob-Gyn name

Midwife/Ob-Gyn phone

Do you (or your family) have any history of depression or other mental/emotional disorders?

Are there any medical issues or concerns we should know about?

Infant Feeding/Care/Sleep | Parenting | Postpartum Goals

How do you plan to feed your baby (breast, bottle, formula, etc)?

Are there specific areas of newborn care you would like more support/guidance (setting a routine, breastfeeding, soothing/calming fussy baby, baby-wearing instruction/guidance, etc)?

Do you plan on having your baby sleep in your room? If yes, where do you want your child to eventually sleep?

Are you comfortable with any crying? If yes, how much? If no, that’s okay too!

Is there anything that you or your spouse/partner may differ on when it comes to your baby and sleep?

If scheduling overnight help, what kind of support is essential when hiring someone (i.e. assistance with baby laundry, help with sleep training, help learning how to take care of a newborn, breastfeeding help, etc)?

Are there specific nights of the week that you want help? *Overnights must be scheduled in advance. Shifts are 10p – 6a

What parenting books have you read?

Are there any parenting techniques you plan to use?

What is your primary goal in utilizing a postpartum doula?

Postpartum doulas are happy to help with some tasks related to running the home. Is there anything specific that could help your new family during this transitional time (light meal prep, light housework/picking up, folding laundry, organizing, etc)?

New Client

Thank you for your response. ✨

All About You

Medical Information/History

Infant Feeding/Care/Sleep | Parenting | Postpartum Goals