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Motherpampering Service Questionnaire
This questionnaire is designed
to help you focus on what your needs may be during your postpartum period. As you focus your needs, I become more
understanding of how I can best assist your particular situation. I will do everything I can do to make
your postpartum period a time of joy and learning. The gentle nurturing of another woman,
who is sensitive to what you may experience can make a significant and
far-reaching difference. It is important that you
understand the purpose of a doula. I
provide emotional and physical support for new parents with the mother being the
primary focus. A well cared for
mother is critically important to the well being of the new baby and the family
as a unit. I offer hands-on
parenting skills with newborn care, breastfeeding support, and care for other
children in the home, and a helping hand in all your meal preparation. I will
also do errands that the mother cannot accomplish such as grocery shopping, dry
cleaning pick up/drop off or driving older children to school or activities. I can accompany you and/or your baby and
children to doctors’ appointments, as needed. If you need someone to do
mainly housecleaning, it may be in your best interest to call a domestic
service, as this is not part of my function as a doula. If
you would like an in person consultation, I will review this questionnaire with
you at that time. [There is a minimal fee of $25 required for this home visit.]
If you do not require a home visit, you may return this questionnaire to me by
mail. We can follow up via
telephone to discuss anything that is unclear.
After we have determined together exactly what services are most
important to you, we will determine the best contractual package to suit our
plans. I
thank you for the time and thought you put into your questionnaire, and look
forward to the opportunity of nurturing and sharing with you through your
postpartum transition. I will
consider your information and customize a care plan to fit your needs within the
next two weeks. Names:
(Please include yourself and your partner) Do
you plan to breastfeed your baby?
Have you taken a breastfeeding
class?
Have
you read any books on breastfeeding?
Please
describe your employment
Are
you planning to return to work?
If yes, how long do you anticipate your maternity leave to be? Will your partner be with you
for a time after the baby is born?
If so, how long?
Do you have any other
supportive family member, or friends, to help you?
Mealtime can be one of the
toughest things to pull together during your postpartum period. I will be happy to prepare the types of
foods you like to eat. You may wish to have your partner do the shopping, or I
can take care of it for you. Would you like me to shop for you?
Does your family have any
special cooking preferences, e.g., no red meat, vegetarian, kosher, low salt,
etc.?
If meal preparation were something you would like me to handle for you, how many meals per week would you like? (When deciding the number of meals, please consider the number of people in your home to be fed and exactly which meals you anticipate needing assistance with. In a normal day, each person should have breakfast, lunch, a snack and dinner. I can make as many meals as you require.) |