Postpartum Intake

First Name *

Last Name *

Phone *

Email *

By checking this box, you consent to receive messages from Queen City Doulas. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Reply STOP to opt-out at any time.

Additional Contact

Would you like to include an additional contact? *

Yes

First Name *

Last Name *

Email *

Phone *

Relationship to Additional Contact *

Address to Receive Support

Address *

Street Address

City

State

Country

Postal Code

Are there any specific instructions to access your home? (ex. gate code, parking location, preferred doorway, etc.)

General Information

Estimated due date, or scheduled induction date: *

Baby's Name

Type of support (check one or both): *

Daytime

Nighttime

Would you prefer to be matched with the doula who we believe is the best fit for your family or would you like to interview multiple candidates? *

Match us!

Send us candidates to review!

Do you have a safe sleep space for your baby? *

Are you planning to (check all that apply):

Breast feed

Formula feed

Feed pumped milk

Daytime Support

How many weeks would you like to reserve daytime support? (a range is fine if you are unsure) *

How many days per week do you need support? (a range is fine if you are unsure) *

Nighttime Support

How many weeks would you like to reserve night support? (a range is fine if you are unsure) *

How many nights per week do you need support? (a range is fine if you are unsure) *

Do you have a place for your doula to rest while your children sleep? (Please note this is required. A couch, futon, bed, or rocking chair that completely reclines are all acceptable. Your doula will only rest while your children as sleeping.) *

Will you be provide linens or would you like your doula to bring her own bed linens? *

We will provide linens

We would prefer our doula to bring her own

Additional Information

Will there be anyone else in your home? (ex. older children, grandparents, etc.)

Do you have any pets? If yes, please share what kind and any info we should know.

Do you have any other expectations or special requests for your doula?

Is there anything you'd like your doula to know?