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Postpartum Doula Services
New Client Questionnaire

Thank you for taking the time to complete this questionnaire. It helps me to support you better!

"*" indicates required fields

Step 1 of 2

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GENERAL INFORMATION

Name*

Name

Partner/Support Person's Name*

Name

Your Home Address*

Street Address Address Line 2 City State ZIP Code

Partner/Support Person's Home Address

Street Address Address Line 2 City State ZIP Code

Phone*

Partner/Support Person's Phone*

Your Email*

Enter Email Confirm Email

Partner/Support Person's Email*

Enter Email Confirm Email

Your Date of Birth*

Month

Day

Year

Partner/Support Person's Date of Birth*

Month

Day

Year

Your Occupation*

Partner/Support Person's Occupation*

HOME ENVIRONMENT

Names and ages of any children in the home?*

Is there anyone else living in the home besides your children and/or partner?*

Are there any animals in the home? What are the names and types of animals? How do you think they will get along with me?*

BABY & BIRTH

Baby's Due Date*

Month

Day

Year

Gender of the Baby*

Girl

Boy

One of Each (twins)

We want a surprise!

Are you expecting multiples (twins, triplets, etc)?*

Yes

Do you have a name picked out? If yes, you can share it with me here if you like.*

Yes

Baby's Name(s)

Where are you planning to give birth?*

Who is your provider?*

What type of birth are you hoping for? (unmedicated, planned cesarean, waterbirth, etc.)*

What concerns, if any, do you have about how your birth will impact your recovery?*

NEWBORN CARE PLANS

Have you and your partner taken/plan to take any education classes in preparation for your postpartum period (newborn care, breastfeeding, infant CPR, etc.)? If so, please list them:

Have you read any books/listened to podcasts to help prepare you and your partner for the postpartum period? If so, please list them:

Do you have experience caring for newborns? How comfortable would you say you and your partner are with caring for a newborn? Are there any questions you have about caring for a newborn?

Are there any parenting techniques that you plan to use or have questions about?

What is your plan for baby’s sleep? What does an ideal sleep arrangement look like for you? Are there questions that you have about infant sleep?*

How are you planning to feed your baby? What worries or concerns, if any, do you have about these plans? Are there ways that you would like me to help with this plan?*

YOUR SUPPORT TEAM

Who do you lean on most for support? How do you see them helping you postpartum? Are there gaps in help that you are feeling you need to fill?*

How do you feel about visitors in the first weeks of baby being home? Are there people that you are planning to have come visit?*

Does your partner plan to stay home after the birth, if so, how much time will they be taking off of work? If you are working, how much time do you plan to take off of work?*

How do you envision your partner helping you over the first few weeks and months once baby is here?*

RECOVERY

Are there aspects of physical recovery from birth that you are nervous about? Anything that you feel like you will need support with from the physical recovery?*

Are there aspects of emotional recovery from birth that you are nervous about? Anything that you feel like you will need support with from the emotional recovery?*

Is there a history of mental health concerns for you or your partner? Do you have concerns with either yourself or your partner struggling with postpartum mood disorders?*

If you have a history of mental health concerns, have you ever been on medication or done counseling/therapy?*

Do you have any alternative care providers (i.e., Chiropractor, Acupuncturist, Homeopath/Naturopath, Massage Therapist, etc.) or any other postpartum care doulas, specialists, lactation consultants, etc.?*

HOUSEHOLD HELP

What household chores are you interested in having help from me with (check all that apply):*

Laundry for baby

Washing Bottles

Sweeping

Meal Prep

Light Dishes

Light/general house pickup

Other…let’s talk about options

Do you, your partner, or other children have food or other allergies, sensitivities, or diet restrictions? (if yes, please list)

Is there anything that you are not comfortable with me helping with?

GENERAL QUESTIONS

What are your primary goals for having a postpartum doula?

Does anyone smoke/vape in the home?

Yes

Are there any medical concerns/complications you feel I should know about, whether during pregnancy or prior?*

What type of self-care and self-nurturing activities do you do for yourself?*

Do you have any personal, religious or cultural beliefs that you would like me to be aware of?*

Do you have plans to keep your placenta for encapsulation or burial and/or another reason of your choice? If encapsulation, would you like me to provide that service as well, or help you find another available encapsulator?*

SCHEDULE FOR CARE

This section is to help me plan for your scheduled care. This plan, including days and times, will be finalized prior to your birth. There is ability to adjust this schedule, if possible, but I require a minimum of two weeks notice if you want to terminate care. I will do my best to follow your needs, however, there may be some need for fluctuation with your request, but this will be communicated clearly to you.

What is your hope for postpartum care support?*

Daytime

Overnight

Combination Day/Night

How many days a week?

How long do you anticipate needing support?

Are there specific days/nights of the week that you are hoping for me to come?

Comments/questions about absolutely anything!*

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"Adrianne provided immediate comfort to Lei when her water broke unexpectedly a month in advance. She stayed with us for most of the labor and delivery, offering advocacy, support, encouragement, wisdom, expertise. She was a constant reassuring presence, greatly reducing the stress of one of life's most stressful occasions. She met with us beforehand and afterwards and shared her experience and advice with warmth and compassion. Highly recommend!"

- Lei & Sean

"...When first meeting Adrianne, we talked and talked and I could tell her calming presence and confidence would be a great counterbalance to my uncertainty and my anxious feelings. Throughout all of our prenatal meetings, she was encouraging and you could tell she valued meeting me where I was at, and gauging what was important to me so she could honor my wishes. Our discussions made me really think through my feelings and thoughts in ways I hadn't considered before, which in turn helped me prepare for the process..."

- Ani

"Adrianne was an incredible listener, really caring to answer my questions/concerns thoroughly. She is very sincere and genuine in her concern for her client. Adrianne was absolutely wonderful in so many ways before, during, and after the birth. She truly went above and beyond, and I could not be more grateful to have worked with her."

- Amy

"Adrianne was such a positive part of our pregnancy and the birth of our daughter! My husband and I are both physical therapists, and we appreciated Adrianne's knowledge on how movements, positions, and breath work could help us to achieve our natural birth goals. During labor and delivery, she was a calm presence and helped us to stay focused on the beauty and power of the time, giving us a sense of control during our birth experience. The prenatal education and postpartum support she provided were invaluable. We would (and have!) highly recommend working with Adrianne as your birth doula!"

- Alaina

"(Adrianne) was the MOST help out of everyone on my team and I can not be more grateful for her. She was so respectful, and I loved the energy she always brought to every challenge that I faced."

- Clarissa

"Adrianne did a fantastic job of guiding my husband and giving him tools so that he could be the most supportive partner possible. He was grateful that we decided to hire her. I would highly recommend Adrianne...!"

- Marian

"She made me believe that I did everything I could. That I was strong. That mattered to me. I am thankful to the moon and back that I had her there."

- Ivory

"Adrianne was a delight to work with for the birth of our son. I truly believe our experience would have been completely different if she hadn't been there to guide and support us throughout the weeks prior to delivery and during labor itself. Adrianne made herself available to me whenever I needed and even came over on several occasions to help me through prodromal labor and guide me to engage baby. I wish I would have had her for our first!"

- Madison

"I wouldn't have been able to get through my natural labor without Adrianne! From the moment I met her I just knew that her calm and comforting spirt would bring me so much ease. She had taken so much time to make sure I was taken care of both physically and mentally for my baby's birth day!"

- Mahayla

"Adrianne was very informative with all things pregnancy, delivery and baby related...My husband and I were so grateful to have her there to help guide us through positions to adjust the baby as I was having horrible back pain. She brought a calming and confident feeling to the intense moments I was experiencing while in labor. She gave the perfect balance of offering a hand, being there to help advocate for my choices while also allowing my husband and I to work seamlessly together..."

- Kimberly

"Adrianne was an essential part of my labor and delivery. Her compassion and gentle approach helped me tremendously. She reminded me and assisted me with moving my body when it was the last thing I wanted to do. Through every scare and worry, I could rely on Adrianne to be there for me. When I experienced a postpartum hemorrhage, she made sure not to leave my side and went above and beyond with her care!"

- Chloe

"Adrianne was so amazing and helpful to not only me, but my partner Shaun! I truly don’t think my birth would have went as smoothly as it did without her! She is so gentle, kind, attentive, and caring. I felt so safe and supported by her."

- Grace

- Lei & Sean

- Ani

- Amy

- Alaina

"(Adrianne) was the MOST help out of everyone on my team and I can not be more grateful for her. She was so respectful, and I loved the energy she always brought to every challenge that I faced."

- Clarissa

- Marian

"She made me believe that I did everything I could. That I was strong. That mattered to me. I am thankful to the moon and back that I had her there."

- Ivory

- Madison

- Mahayla

- Kimberly

- Chloe

- Grace

Contact Me for a Free Consultation

Let's Chat

I feel passionate about helping others find their courage, strength, and instinct to trust their bodies and step into their power to have the birth experience they want. It is an honor to walk alongside you, hold space for you and allow the physiological process of birth to unfold.

Serving the Greater Tacoma, WA area including Puyallup ~ Sumner ~ Bonney Lake ~ Federal Way ~ Auburn ~ Gig Harbor ~ JBLM ~ Olympia ~ Lacey

~And other surrounding South Sound cities~

(253) 254-5142
adriannebuyer@gmail.com

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