Parent Name
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First Name
Last Name
Parent Name
First Name
Last Name
Home Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email
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Calls, text, or emails preferred?
How did you hear about Green House Doula or who referred you?
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Are you taking time off work? If yes, for how long?
Is your partner taking time off work? If yes, for how long?
Do you have any other expected assistance during this postnatal period (family, friends, sitters, etc.)?
Baby's Name and DOB/Due Date
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Are there any other siblings or children in the home? If yes, what are their ages?
What is your personal experience with newborns?
What is your current feeding plan for your baby? Breastfeeding, formula, combination, exclusively pumping, supplemental feeding system, or other (please specify)?
What is your plan for your baby's sleeping arrangements?
Are you aware of and up-to-date on the American Academy of Pediatrics (AAP) safe sleep recommendations?
Do you have a specific parenting style, philosophy, or any techniques that resonate with you or that you plan to implement?
Please list any classes, books, websites you’ve enjoyed regarding parenting, newborns, sleep, lactation/feeding, etc?
Do you have any history of medical or mental health challenges?
Have you experienced any complications or medical concerns during pregnancy or birth?
Do you have any current medical concerns that I should be aware of? If yes, is there any additional support you may need?
Does your baby have any known medical concerns, diagnoses, allergies, or special needs, etc?
Are you consulting with any other specialist support for yourself or your baby (Lactation Consultant, Chiropractor, Craniosacral Therapist, Myofascial Therapist, etc)? If yes, please list.
Are there any specialists that you would like recommendations for?
Does anyone in your home have any allergies, special dietary needs or restrictions? Please specify.
Do you have any pets? If yes, please list.
Is anyone in the home a current smoker?
Do you have any weapons or firearms stored outside of a locked safe in your home?
Is there anything in particular about your home environment that you'd like to share or that would be helpful for me to know?
What are your primary goals, wishes or desires for Postpartum Doula support during your recovery or in the early weeks postnatally?
How many weeks do you currently anticipate needing Postpartum Doula support?
How many days per week are you looking for support? Are there any specific days of the week that you might prefer if available?
What time of day do you anticipate support would be most needed?
Describe household chores, tasks, or educational topics you’d enjoy having support with during visits.
Are there any household tasks or general tasks that you do not want help with or prefer to do yourself?
Do you have any fears or concerns about parenting or the postnatal period that you are open to sharing?
What excites you the most about parenting and your new baby?
What ways do you enjoy recharging or supporting your own self-care?
Do you ascribe to any particular love languages or ways that you feel most loved and supported by others?
Is there anything else you would like for me to know about your family or other information that you feel would be helpful for me to know?
Does your family have any preferred pronouns, terms, or language that I can support?