Client Questionnaire   
www.doulasofpalmbeach.com
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First and Last Name  *
Full Home address (street, city, state, and Zip )  *
email address  *
Phone number 
What services are you requesting? *
When are you due or how old is the baby ? *
If you are looking for postpartum care ( Night or day time ) Please let us know if you are looking for guidance about your baby or do you have an already established routine you want help with?  We want to know how to best help you and if you want education and guidance or practical help only. 
Are you using Carrot Fertility, HSA Or FSA etc? If you are, what are your benefit limits? (6 weeks, amount of policy, is it lifetime or yearly renewable etc. this helps us be able to bill correctly and know if you have any extended out of pocket cost. ) 
Please tell us anything that you are specifically looking for help with. example: " I am having pain while breastfeeding and need a consult" or " my baby isn't gaining weight" or, " I hope to have someone come for nights and days for the first month to help me 5 days a week"  It is okay if you don't know specifics, but if you do or have an idea, it helps us find the best match for you. *
For postpartum doula services only: 
Pricing quotes is done by the hour. Please give your best guess on how many hours  a night, how many days a week, and how many weeks or months you think you want help. If you don't know, we can discuss to get an estimate. 
Do you have pets in the home? If yes, please let us know which ones. We try to not send professionals with allergies to homes with those animals. 
Is there anything you would like us to know about your family ? Anything specific about the baby? Example: The baby was born premature, OR a parent has a physical disability and may need help picking up the baby, allergies of any kind or we may need extra help as we are planning a cesarean etc. 
Is there anything culture wise, or general house rules we need to adhere to coming to your home? Example: Remove shoes before entering the home, or Only use a certain bathroom, or don't use certain cutlery etc. 
Have you used this type of service in the past? What did you like or want different this time?
Anything else you would like us to know?
How did you hear about us ? *
Generally after this is filled out we have a connection call so I can get to know more about you and what you need and answer any questions. Would you like to chat via Phone, zoom or prefer text?  *
todays date  *
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