Care Request Form - Birthways, Inc. Chicago Doula Services

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Pregnancy & Birth
Breastfeeding & Lactation
Postpartum & Newborn
About
- About
- Our Team
Classes
Help Center
- Articles
- FAQs
- Contact Us

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Postpartum Doula services

Care Request Form

Thank you for your interest in Birthways Postpartum Doula services! Please complete the Care Request Form. You are welcome to call us at 888.506.0607 x705 with any questions or to complete by phone.

"*" indicates required fields

Parent 1 Name*

First Last

Parent 2 Name

First Last

if applicable

Estimated Due Date or Baby's Date of Birth*

MM slash DD slash YYYY

Parent 1 Phone*

Parent 1 Email*

Parent 2 Phone

Parent 2 Email

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

What is Parking like around your home?*

Free Street Parking

Permit Street Parking

Metered Street Parking

Paid Lot/Garage - attached to building

Paid Lot/Garage - separate from building

Driveway/Off-Street Parking

Neighborhood or Nearest Cross Streets*

How many babies are you expecting?*

Baby's Name/s*

if chosen

Please share if you are welcoming a baby through adoption or surrogacy.

If you have other children at home, please share their names & ages*

If there are any pets in the home, please share what kind of animal/s & name.*

Name of Birth Location*

Name of Doctor/Midwife*

Name of Pediatrician*

I am looking for postpartum/post-arrival care that is:*

In-person only

Virtual only

Combination of In-person and Virtual

I'm not sure yet

I want*

Daytime Support

Overnight Support

Combination of Day & ON (specify below)

Please tell us your Ideal Postpartum/Post-Arrival Schedule

Most of our clients aren't sure what their care plan should look like. If you have a preference, please tell us more about that here.

We plan to begin care:*

Within the first week of baby's arrival

As soon as possible - baby is already here!

We have another date in mind

How many weeks of care are you planning at this time?*

Priorities for Care

Nursing Guidance/Support

Guidance/Caring for Newborn

Guidance/Caring for Self

Emotional Support

Sibling Care

Household Support

Meal Planning/Preparation

Errands/Carpooling

Prevention of Perinatal Mood Disorders

Does any one in your home have any food allergies or dietary restrictions?*

Do you have any Cultural Customs or Traditions we should know about?*

Please share anything else you would like us to know about your family!*

Please inform us as to your household circles/interactions during the Covid Pandemic, so that we can best match you with doula support.

How did you hear about us?*

Chanel-washington

Ilana

Jessica

Megan Trinter Birthways Chicago

Rhona

Sonrisa

Founded in 1997

Not just another doula or childbirth education provider...

When you work with Birthways, you benefit from partnering with nationally recognized experts and the most experienced doula service provider in the Chicago area.

Learn More About Our Doulas

In the Chicago Area?

Schedule a call to inquire about in-person doula support to ease your stress. Whether through pregnancy, labor, postpartum, breastfeeding or all of the above - we're here to help.

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