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Birthing person's name:
Your answer
Birthing person's phone number:
Your answer
Birthing person's email:
Your answer
Due date (if applicable):
MM
/
DD
/
YYYY
Partners name or Support Person (if applicable):
Your answer
Partners or Support Person number (if applicable):
Your answer
Area lived in/Address:
Your answer
If you have other children, please list names and ages:
Your answer
If you have pets, please list type of animal:
Your answer
Are there any known allergies in your family?
yes
No
Clear selection
If you selected yes above, please list allergies:
Your answer
Does anyone smoke in the home?
Yes
No
Clear selection
Birthing person's occupation:
Your answer
Partners occupation or Support Person (is applicable):
Your answer
Are you taking time off? If yes, how much time?
Your answer
Is your Partner or Support Person taking time off? If yes, how much time?
Your answer
What are your primary goals for having a postpartum doula?
Your answer
Do you have any fears about your upcoming birth, postpartum, or parenting?
Your answer
Are there any medical concerns you feel I should know about?
Your answer
How do you plan to feed your baby?
breastfeeding/chestfeeding
formula
pumped milk
combination
Clear selection
Do you know when you will want postpartum doula services?
day
evenings
overnights
combination
Clear selection
Would you like to be added to our mailing list?
Yes
No
Clear selection
Anything else I should know about your family or that you would like to share?
Your answer
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