Fern Blessings

Prenatal & postpartum doula services

Due Date:______________________
Mother:__________________________ Mothers date od birth:_________________________
Number: (_____)___________________
Partner:_________________________________ Number: (_____)______________________
Email address:__________________________________________________________________
Children or, pets to know about (names & ages):______________________________________
______________________________________________________________________________
Allergies I should know (whole family):______________________________________________
Beliefs:________________________________________________________________________
Address:_______________________________________________________________________
Certain directions to address (just after yellow mail box):________________________________
______________________________________________________________________________
Who do you have for support (family, friends, therapist):________________________________
______________________________________________________________________________

Basics:
Why do you want a doula? What do you expect or want?_______________________________
______________________________________________________________________________
Is there anything I should know?___________________________________________________
______________________________________________________________________________
Have you been through any trauma? Yes___ No___
If yes are you comfortable talking about it? Yes___ No___
Any worries or fears?____________________________________________________________
Do you want a birth plan? Yes___ No___
Would you like child birth education? Yes___ No___
Certain equipment needed?_______________________________________________________
______________________________________________________________________________
Comments?____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Pregnancy
How has the pregnancy been?_____________________________________________________
______________________________________________________________________________
Care provider?__________________________________________________________________
Can I talk to your care giver about the care I give you?__________________________________
Do you have any worries, fears, or concerns?_________________________________________
______________________________________________________________________________

Labour/Birth
What kind of birth do you want?___________________________________________________
______________________________________________________________________________
Birth wishes?___________________________________________________________________
Place to labour?_________________________________________________________________
Place to birth?__________________________________________________________________

Who will be attending?___________________________________________________________

Post-partum (Doulas part)
Baby(s) name:___________________________________
Date of birth:____________________________________
Gender:____________
Weigh/Length:__________________/________________________
Feeding how:____________________________________
Notes:________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

How many Prenatal & Postpartum meetings (to discus at our meeting)
Prenatals:
1)_____________________
2)_____________________
3)_____________________
4)_____________________
More?________________________________________________________________________
Post partums:
1)_____________________
2)_____________________
3)_____________________
4)_____________________
More?________________________________________________________________________

Payment: