Postpartum Client Intake FormThis questionnaire will help me prepare for our first meeting.Please answer as thoroughly as possible and reach out with any questions. About You & Your Family Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Age * Occupation * Partner's Name * First Name Last Name Partner's Phone * (###) ### #### Who else will be in the house during our postpartum sessions? Please include any other children and their ages. Do you feel like you have community/family support in the immediate area? How do you plan to use their support in your postpartum period? If you work, when are you planning to return to work? If your partner works, when are they planning to return to work? Preferences What is your preferred method of communication? * Phone Call Text Email If cooking is something you plan on having me assist with, are there any dietary restrictions in your household? What is your favorite comfort food? What do you find helpful when you feel stress? Please list any other preferences you have when someone is in your home (ie taking shoes off, knocking vs ringing the doorbell etc) Services/Tasks In what ways would you like your doula to support you and your partner during our postpartum visits? What are some of the household tasks you anticipate I might help with? Do you have any specific questions about newborn care? Classes/Preparation Please check the classes you have taken or plan to take: Breastfeeding Newborn Care CPR/First Aid Parenting Class Other What are your go to sources for information (books, websites, podcasts etc) about pregnancy, birth, parenting or newborn care? Anything else you would like me to know about you or your postpartum period? Previous Postpartum Experience(s) Please tell me about previous postpartum experiences. What was the best thing about your last newborn experience? List any post-pregnancy discomforts or complications you experienced. Thank you!
