Jevidy Doula
Postpartum Intake
Client Name:
First Name
Last Name
Preferred name (if applicable)
Baby's Name:
First Name
Last Name
Baby's Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Female
Male
Support Person (main):
First Name
Last Name
Relationship:
Client Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client Phone:
Format: (000) 000-0000.
Client Email:
example@example.com
Preferred communication:
Text
Phone
Email
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Household Information
Who lives in the home?
Other children?
Yes
No
Ages:
Type a question
Dog(s)
Cat(s)
Other
Name(s) and Breed(s)
Birth Information
Birth Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Birth Type:
Vaginal
Assisted Vaginal
Planned Cesarean
Emergency Cesarean
Were there any complications?
NICU Stay?
Yes
No
Length:
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Feeding
Baby is currently:
Breastfeeding
Chestfeeding
Bottle Feeding
Formula Feeding
Combination Feeding
Are you experiencing feeding concerns?
Yes
No
Explain:
Parent Recovery
How are you feeling physically?
Are there any restrictions from your healthcare provider?
Current medications:
Any allergies?
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Emotional Well-Being
How are you feeling emotionally?
How are you feeling emotionally?
Great
Good
Overwhelmed
Anxious
Sad
Unsure
Have you experienced:
Have you experienced:
Perinatal Mood symptoms such as postpartum depression or anxiety
Birth trauma
None
Other
Would you like referrals to mental health resources if needed?
Yes
No
Sleep
How many hours of sleep are you getting in a 24-hour period?
Who helps overnight?
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How Can I Best Support You?
Select all that apply.
Newborn care education
Overnight newborn care
Daytime newborn care
Infant Soothing
Feeding support
Emotional support
Meal preparation
Light household tasks
Infant laundry
Sibling adjustment
Self-care planning
Community resource referrals
Other
Any special care requests or instructions you would like to share:
Visitor Preferences
Would you like visitors during doula visits?
Yes
No
Quiet household preferred?
Yes
No
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Household Safety
Do you have pets?
Dogs(s)
Cat(s)
None
Other
Name(s)/Breed(s)
Is anyone currently ill?
Yes
No
Anything I should know before arriving?
Emergency Contact (only for use in a true emergency)
Name:
First Name
Last Name
Relationship:
Phone:
Format: (000) 000-0000.
Address (if different):
OB/Midwife:
Pediatrician:
Any other known providers:
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Consent
I understand that my postpartum doula provides non-medical emotional, educational, and
practical support and does not replace medical or mental health care.
Client's Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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