Client and Family Information
This form is for Sooner State Doula Postpartum Clients. Congratulations on your pregnancy! This will give me a better understanding of how I can best support you and your partner. Thank you for taking the time to fill out this form. Please complete this form after signing your contract and paying your deposit.
Family Information
Name
First Name
Last Name
Mother's Phone Number
Please enter a valid phone number.
Occupation
Are you taking time off work? If so, how much
Partner / Birth Support's Name
First Name
Last Name
Partner / Birth Support's Phone Number
Please enter a valid phone number.
Partner / Birth Support's Occupation
Is your partner taking time off of work? If so, how much?
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your preferred method of communication
Phone call
Text
Email
Do you have any other children living in the home?
Please include their name and ages
Is there anyone else living inside the home? Do you have any pets?
What is your go to coffee/tea/smoothie order? Or favorite treat?
Pregnancy Information
What number pregnancy is this for you?
What number birth?
When is your estimated due date / baby's date of birth?
-
Month
-
Day
Year
Date
What is your OB/ Midwife's name?
Where are you planning to give birth?
Baby's gender?
Please Select
Boy
Girl
Unknown
Baby's name? (If you would like to share!)
Type of delivery (planned or actual)
Please Select
Vaginal
Cesarean
During pregnancy or labor and delivery, did anything happen that you were upset, traumatized by, or otherwise not expecting? Is there anything else about the birth that I should be aware of in order to serve you better? (Ex: postpartum health concerns, hemorrhage, extensive tearing, NICU stay etc)
Are there any medical issues or concerns we should know about?
Planned method of feeding?
Please Select
Breastfeeding
Exclusively pumping
Formula feeding
Combination of the above methods
Not sure, I could use some more information before I choose!
Postpartum Expectations
Do you (or anyone in your household) have any allergies that I should be aware of?
Do you have a preferred style of cooking, or any dietary restrictions?
Does anyone smoke inside of the house?
Please Select
Yes
No
Are there any parenting techniques you plan to use?
What parenting or infant care books have you read? (if any) Have you taken any classes?
Do you have any fears about your upcoming birth, postpartum, or parenting?
What areas of postpartum care do you anticipate needing assistance with?
Breastfeeding, pumping, or bottle feeding support
Support and education on infant sleep
Support and education on infant care
Assistance with baby soothing
Providing infant care so parents can rest
Light care for siblings
Light basic household tasks
Meal preparation
Assistance with small errands
Assistance with after birth healing (sitz baths, emotional support etc)
Other
What is your primary goal of having a doula?
Are there any areas of newborn care you would like more support/guidance? Ex: breastfeeding, setting a routine, soothing/calming a fussy baby, etc
Do you or your family have any history of depression or other emotional disorders? (Postpartum or otherwise)
Have you had any recent major changes in your life (family/friend death, a recent move, job change)?
Is there anything on your mind right now that you want your doula to know?
Doula Limitations
I understand that my doula will not perform any clinical assessments or medical procedures.
*
I understand
I understand that my doula is not a nanny or a babysitter. My doula may provide care for my infant or other children while the parents rest, but she will not take over the role of primary caregiver of my child(ren).
*
I understand
I understand that my doula would be happy to help with light daily household tasks such as dishes, laundry, and sweeping but she will not perform any major cleaning tasks.
*
I understand
I understand that my doula will not drive my vehicle, or any member of my family in her vehicle for any reason.
*
I understand
I agree that if I ask my doula to run any errands (ex: pick up coffee, grab a gallon of milk, run to the store for diapers) I will compensate her on the same day for the cost via venmo, cash app, or cash. My doula will not take my debit/credit card to the store with her for such errands.
*
I understand
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