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.

Names: (Please include yourself and your partner)

Baby’s Due Date __________________________________________________________________________

Consultation Date *________________________________________________________________________

Street address:__________________ City:_______________ State: _______Zip Code:__________________

Phone:  Daytime:______________________ Evening: ______________________ Cell:____________________

Email Address:______________________________________________    

Mother’s Age: _______________Father’s Age:__________________

Do you plan to breastfeed your baby? _____________   Have you taken a breastfeeding class?___________

Have you read any books on breastfeeding?___________ Are you currently working?______________

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.)__________________________________________________

Is this your first baby?  If not, what are the names and ages of your other children?

Name	Age

Do your children have any special needs, either physical or emotional?__________________________________

Do they have scheduled activities I should know about?_____________________________________________

Do you have other childcare providers who will be helping with the other children?_________________________

What may be some of your family’s needs concerning the care of your home, errands etc.?___________________

______________________________________________________________________________________

My first priorities are the care of the mother (and father), the infant and the children.  When everyone is comfortable and satisfied, I will remain busy with washing, drying and folding all laundry and changing and making beds, as time permits.  Is there anything else you feel would be helpful for me to know?_______________________________

Do you have any pets that need taking care of during our employment?_____ If yes, what type of pets and what are their names?____________________________________________________________________________

I try to be very flexible in terms of scheduling. In order to insure my availability for you, please try to estimate how long do you anticipate needing my services.  Would you prefer to plan for 2-5 days per week on a monthly basis or 2-5 days for one week? _____________________________________________________________________________________

Days per week:_____________ Weeks per month:_____________ Number of months: ___________________

How did you hear about me?_________________________________________________________________

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.  

Here’s to a very healthy, happy delivery!