Parent (1) Name
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First Name
Last Name
Occupation
Parent (2) Name (if applicable)
First Name
Last Name
Occupation
Location or Address (if applicable)
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Email
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Phone
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Preferred Method of Contact (select all that apply)
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How did you hear about Green House Doula?
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Who currently lives in your household?
Does your family have any preferred pronouns, terms, or language that I can support?
How do you practice self-care? (favorite activities or hobbies, how often, etc.) How has this changed since having your baby?
Describe your support systems (people in your life who provide you with support).
Baby's Name and Age (in months)
Baby's Date of Birth. Were they late, early or on time?
Baby's Birth Weight
Do you have another child? If yes, please provide their name and age.
Please tell me about your baby. Who are they? What are their best qualities? What do you find most challenging about their personality?
Where is your baby/child on the growth charts? Are they following their growth curve?
If your baby has fallen off the growth curve, at what age did this happen? What has your child's pediatrician said about their weight?
Is your baby meeting all their milestones? Are there any specific milestone they're currently working on?
Are there any health concerns or allergies I should be aware of? Have you discussed these with your baby's pediatrician?
What is the overall health of your baby? Are they often sick?
Has your baby ever been hospitalized for any type of medical condition? If yes, please describe.
Is your baby currently taking any medication or any supplements/probiotics? If yes, please list below.
Please check all that apply:
Is your baby teething, recovering from illness, or other? Please describe in detail.
Are you working with any other specialists or practitioners in addition to your baby’s pediatrician? (Lactation Consultant, Chiropractor, Craniosacral Therapist, Occupational Therapist, Physical Therapist, Naturopath, etc.)
Is your baby extremely sensitive to touch, taste, smell, or light and dark? Does your baby seem to really dislike tooth brushing, hair brushing, bath time, getting dressed, etc? Do you find your baby prefers more aggressive bouncing or rocking? Do they like rough and tumble play? Please describe.
Does your baby drink breastmilk, formula, or both?
Is your baby eating solid foods? If yes, at what age did they start? Are you giving purees or using baby-led weaning?
Has your diet or your baby's diet recently changed?
Do you have any concerns about feeding you would like to share?
Have you previously worked with a Lactation Consultant? If yes, when was your last visit?
If you are breastfeeding, what are your long-term breastfeeding goals?
If you are breast or bottle feeding, have you noticed:
If your baby is over the age of 12 months, have you noticed:
Are you, or another adult who is close to your baby ill, exceptionally busy, or going through an emotionally difficult time?
Is there anything else that may be going on in your house that might be affecting your baby? Parent arguments, new nanny, new baby, a job change, a move, daycare?
Please describe the amount of time you spend with your baby and the types of activities you do together.
How much time does your baby spend playing outdoors?
How much time does your baby get per day to move freely and explore (not in a stroller, seat, or other baby container)?
Have you been away from home more than usual or taken a trip/family vacation? If yes, please describe.
Is your baby in any type of childcare (daycare, nanny, etc)? If they yes, how you feeling about the childcare and how is your little one adapting?
Tell me how you feel about tears. How do you respond to tears/frustrations from your baby during the day? Is it a priority to make those tears stop?
Do you use any type of discipline? If yes, please describe the type of discipline you use.
Are you feeling any pressure about your parenting choices from people around you? Extended family?
Please check all that apply:
If your baby sleeps in more than one location, please give me an idea of when your baby/child changes locations throughout the night.
What is the exact room temperature during the day? At night?
Please check all that apply. We use:
If "other", please describe.
What does your baby sleep in? Please describe the fabric of the pyjamas, are they footed? Are they tight? Are there any tags? Etc?
Describe the lighting in your baby's sleep environment (pitch black, night light, light from hallway).
If your baby wakes at night, do they fall back asleep independently or do they need support from you? If they need parental help, what is it that you need to do - please describe in detail.
Do you have a nighttime routine? If yes, please describe in detail what you do and how long it takes.
Do you have a nap time routine? If yes, please describe in detail what you do and how long it takes.
When your baby is upset at night, what do you find is the best way to calm them other than feeding? Please describe.
Have you ever done any sleep training? If yes, please describe IN DETAIL - the method, whether you saw any success, if you used a sleep consultant (it is helpful if you provide a name so that I have a better idea of the approach used).
Do you have any particular questions or concerns that you'd like to discuss on our call?
Are there any goals that your family is currently focused or working on?
Is there any additional information that you feel would be helpful to share?