Dinner and a Doula Intake Form | YVR Doula Services

First name

Last name

Phone

Email

Address

Do you have any allergies or dietary restrictions? If so, what are they?

Your 3-Course Meal (please pick one of each)

Appetizer- Kale and Sweet Potato Soup with chicken chorizo and smoked paprika

Appetizer-Pumpkin and Squash Ravioli with roasted pumpkins and crispy kale

Main Course-Pesto baked Chicken thighs with grilled asparagus and Quinoa salad

Main Course-Crispy Skin Salmon Fillet with roasted vegetables and chickpea puree

Main Course (Vegan) Roasted Butternut Squash with chestnut stuffing. Served with grilled broccoli and braised red cabbage

Dessert- Avocado Chocolate Mousse

Dessert- Maple Pot de Creme with Fresh Fruit

Partners 3-Course Meal (please pick one of each)

Appetizer- Kale and Sweet Potato Soup with chicken chorizo and smoked paprika

Appetizer-Pumpkin and Squash Ravioli with roasted pumpkins and crispy kale

Main Course-Pesto baked Chicken thighs with grilled asparagus and Quinoa salad

Main Course-Crispy Skin Salmon Fillet with roasted vegetables and chickpea puree

Main Course (Vegan) Roasted Butternut Squash with chestnut stuffing. Served with grilled broccoli and braised red cabbage

Dessert- Avocado Chocolate Mousse

Dessert- Maple Pot de Creme with Fresh Fruit

Would you like me to pick up anything in advance to make the night special? like wine or flowers, etc?

Will another couple be joining you for dinner? *$200 more/ per couple*

Do you have other children who will need to be minded? * $10/ per child/ per hour*

Are you recovering from surgical birth?

Yes- I had a cesarian section

No- I had a vaginal birth

I have fulled recovered from my birth

How are you currently feeding your baby? Any concerns or issues?

Do you have any pets? If so, please provide breed and temperment

Is there any additional information that you would like me to know so that I can better support you?

Which Date were you hoping for? **Subject to availability

Signature

DINNER AND A DOULA INTAKE FORM $400 + GST