Postpartum Doula Intake Application
Please fill out this form before your complimentary consultation call
Samantha Stengle, Moss and Moonlight: Sanctuary for Healing Arts
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Email *
Name *
Phone *
Your gender identity
 *
What are your primary goals for having a postpartum doula? *
Required
When is your expected due date? *
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YYYY
Where do you intend to give birth? *
Required
Have you had any difficulties, complications or restrictions with this pregnancy (emotional, mental or physical)?
 *
Required
Are you planning to breastfeed or bottle feed?
Address where you reside/will need Postpartum Care *
Who else lives in the home or will be there during my shifts? (Names and ages of partner, other children, housemates, pets, etc) *
If you are taking time off of work, how much time will you be off? *
If your partner/support person will be taking off work, how much time will they be off?
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Do you have any medical issues or disorders I should know about?
Do you have a spiritual belief system? Or do you/your family have any religious or cultural beliefs I should know about?
 *
I only offer daytime shifts. If you choose to work with me, I can attempt to bring in another postpartum doula who offers overnights. What shifts are you looking for? *
Required
Do you have any specific vision or hopes for your postpartum time?
Is there anything else I should know about you, your pregnancy, your birth, expectations as your doula or specific help you're seeking, or why you think I would be a good match for you?
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