Welcome Baby KC Postpartum Intake

Welcome Baby KC Postpartum Doula Services

Nicole Elliott Bays
To individualize your care for the best experience possible, please take a moment to fill out this Needs Assessment .

I will use this Needs Assessment as a tool to get to know you better.
Full Name:*

First NameLast Name
Email
example@example.com
Babies Date of Birth*

MonthDayYear
Date
Cell Phone #*

Area CodePhone Number
Occupation
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Partner/Spouse's Name
Partner/Spouse's Cell #

Area CodePhone Number
Provider Name
Planned Place of Birth
Baby's Name (if known)
Baby's Name (if known)
Baby's Sex (if known)
Baby's Sex (if known)
Planned Method of Feeding*

Bottle - FormulaBreastfeeding OnlyMix of BothBottle - breastmilk
Will Baby Be Circumcised?

YesNoUnsureWould like more information
Does your family have special dietary needs or preferences? Favorite meals? Least favorite meals? Allergies?
Explain in detail any complications with this pregnancy and any restrictions you have been placed on by your caregiver, including listing any medications you are currently taking.
Tell me about your baby's birth; either your birth plans or actual events if your baby has already arrived.
Are you currently experiencing or anticipating any specific challenges after your baby's birth?
Take a long moment to consider what you'd like your postpartum time to look like. What are 3 goals that are most important to you? (If you need help with this question, skip it, and contact me ASAP. We'll work on this question together.)
Do you or anyone in your home have any conditions that your postpartum doula should beaware of in order to provide safe, sensitive care? If yes, please describe.
If you're employed, how long will you be taking off work after the baby's birth?
If your partner/main support person is employed, how long will he/she/them be taking off work after the baby's birth?
Does your family have any particular cultural or religious traditions I should knowabout?
What is your love language? Sharing your love language with me tells me how I cantailor your postpartum doula care to meet your emotional needs as a postpartumparent. Please select your top 2 love languages.

TouchWords of AffirmationQuality TimeGiftsActs of ServiceI don't know.
How much and how often will you need your postpartum doula in your home?What you put here is for approximate scheduling purposes only. You are not bound tothis schedule in any way.
The first day you'll need me is:

MonthDayYear
Date
How many days per week approximately:
If you have older children, please share their names, ages, and a little bit about each of them.
If you have pets, please share their names, ages, and a little bit about each of them.
Please describe any topics that you would like help with, or more information about.
Internet & Password- If you feel comfortable share so I can sign on while I'm at your home.
Today's Date
Please sign:

Clear
WIFI blanks Password blank If you don't feel comfortable sharing password that is fine you can keep it a secret and fill it out when I get there or you don't have to share at all.
Should be Empty:

Welcome Baby KC Postpartum Doula Services