Professional Newborn Care Specialist Inquiry Form
Client Information
Parent/Guardian #1
Full Name:
First Name
Last Name
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Parent/Guardian #2
Full Name:
First Name
Last Name
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Home Address:
Preferred Method of Communication:
Preferred Method of Communication:
Phone
Text
Email
Pregnancy Information
Estimated Due Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
OB/Midwife:
Hospital or Birth Center:
Is this your:
Is this your:
First Baby
Second Baby
Third+
Twins
Triplets+
Baby's Sex (if known):
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Is the pregnancy considered high risk?
Yes
No
If yes, please explain:
Planned delivery:
Vaginal
Scheduled C-section
Unsure
Family Information
Will there be older children in the home?
Yes
No
If yes, please list ages:
Pets:
Dog(s)
Cat(s)
Other
None
Anyone in the home smoke?
Yes
No
Services Requested
Please check all services you're interested in:
Overnight Newborn Care
Daytime Newborn Care
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Twin/Multiples Support
Feeding Support (Breastfeeding & Bottle Feeding)
Newborn Routine Development
Sleep Shaping & Healthy Sleep Habits
Infant Laundry
Infant-Related Organization
Nursery Organization
Light Infant-Related Housekeeping
Overnight Parent Support
Other:
Schedule Requested
Preferred Start Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Estimated End Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How many weeks of care are you interested in?
Preferred Schedule:
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
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Sunday
Preferred Hours Each Day:
Preferred Number of Hours Per Week:
Overnight Care
How many nights per week are you hoping for?
Preferred shift:
8 PM-6 AM
9 PM-7 AM
10 PM-6 AM
Other
Will baby sleep in the nursery?
Yes
No
Unsure
Feeding
How do you plan to feed your baby?
Breastfeeding
Pumping
Formula
Combination
Unsure
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Would you like overnight bottle preparation?
Yes
No
Sleep Goals
What are your biggest concerns about bringing baby home?
What are your biggest goals for newborn care?
Have you previously hired an NCS?
Yes
No
Home Environment
Will the NCS have:
Private bedroom
Private bathroom
Quiet area for breaks
Parking available
Any stairs the caregiver should know about?
Medical Information
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Will baby have any known medical concerns?
Any anticipated NICU stay?
Any allergies in the home?
Expectations
What are the three most important qualities you're looking for in an NCS?
Are you prepared to sign a contract and pay the required retainer to reserve your dates?
Yes
No
I have questions.
Additional Information
Is there anything else you'd like me to know about your family or your expectations?
Next Steps
Thank you for your interest in newborn care services. After reviewing your inquiry, I will contact you to schedule a complimentary consultation to discuss your family's needs, answer any questions, and provide a personalized quote. Contract dates are reserved only after both the service agreement has been signed and the required retainer has been received.
Please sign to confirm all information provided is correct:
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