Email (required)

How would you describe your birthing experience? Select all that apply.

Traumatic Did not go as planned Just as I expected Beautiful / Euphoric

Method of birthing / labor

Vaginal C-Section Emergency C-Section

Any unplanned medical interventions during your birth? So we can better assist your in-home recovery.

Were you discharged from the hospital in good health?

Yes No

Did your baby have to stay in the NICU before discharge?

Yes No

If yes, why / for how long?

Baby's Sex

Male Female

Are you open to using a pacifier to soothe your infant?

Yes No Unsure

Are you currently taking any medications? Please list everything, including supplements. Dana will review with you.

Is anyone in your home living with allergies or sensitivities? Please list the person and what they're allergic/sensitive to.

Anyone else in the home providing support for you and baby? Name & role — we work collaboratively in your care.

Would you like our Care Team / doulas to wear a mask while in your home?

Yes No

Have you or your immediate family been exposed to RSV or COVID in the past 14 days?

Yes No

Are you or your baby currently experiencing any symptoms? Fever, chills, cough, shortness of breath, loss of taste/smell, upset stomach, vomiting, or diarrhea in the last 24–48h.

Have you ever been diagnosed with a mental health condition? Not required — skip if you prefer.

How would you describe your emotional state over the past week? Select all that apply.

I've been feeling calm or stable I've felt overwhelmed or stressed I've had trouble sleeping or eating I've had intrusive or upsetting thoughts I've felt sad, hopeless, or withdrawn

Would you like help connecting to emotional wellness or mental health resources?

Yes No

Current anxiety level 1 – 10

Your Medical & Safety Details