Postpartum Doula - Intake Birthing Person's - Name First Last Birthing Person's - Date of Birth MM slash DD slash YYYY Birthing Person's - Do you identify as Aboriginal? Yes No Birthing Person's - PhoneBirthing Person's - Email Birthing Person's - Address Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Birthing Person - Emergency Contact Do you have a partner with this child? Yes No Parenting PartnerPartner's - Name First Last Partner's - Date of Birth MM slash DD slash YYYY Partner's - Do you identify as Aboriginal?You may be eligible to for grant through The Doulas for Aboriginal Families Grant Program (DAFGP) Yes No Partner's - PhonePartner's - Email Partner's - Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Health Care Provider(s) Family Doctor Doula & Support Team Baby's Name (If decided) First Middle Last Baby’s Gender (If known) Expectant Due Date MM slash DD slash YYYY Baby's Date Of Birth (If born) MM slash DD slash YYYY Specific details (single baby/twins, age), date/hour preferences, what support you are looking for, etc: Please note, we will try our best to accommodate, but can not guarantee fulfillment of all specific requests. How many children have you had? How many children does your partner have? Are there other children in the home? Other adults? (Names & relationships)How is life with baby going? Any issues that is encouraging you to seek/utilize these services?Is baby breastfeeding or bottle feeding? Are there any aspects to feeding you wish were different or you are struggling with?Do you currently have or have a history of mental illness?Does your partner or any other adult in the home currently have or have a history of mental illness?Do you feel like there are any issues you are struggling with that is affecting your postpartum (health, financial, etc)How is your mood? How is your partner’s mood? Is there anything in particular that we could help you transition and adjust? Is there anything you’d like some education on or any particular issues you’d like to solve? What other support services are you accessing? What other support/assistance do you have? Family/friends, etc..Do you or anyone in the home have any health concerns and/or blood born illness? (diabetes, HIV/Aids, Hepatitis, etc) Do you have any medical issues? Are you taking any medications?Does your parter have any medical issues? Are they taking any medications?Any Other Additional InformationCAPTCHA
