Mommy's First and Last Name

Daddy's/Partners First and Last Name

Other Cell Phone Number

Home Phone Number

Mommy's Email Address

Mailing Address

Address Line 2

City

State (2 letter abbreviation)

Zip

Address where services will be performed: Address where services will be performed: check box if different than Mailing address.

Home Address

Address Line 2

City

State (2 letter abbreviation)

Zip

Occupation of both parents/partners

How would you describe your personality?

How would you describe your partner's personality?

Describe how you would like your Baby Nurses interaction with you to develop? For example: Stay in the background except to bring you baby and fix meals, or be more a part of the family in your space always available to answer questions. Sit with you while you breastfeed, or bring you baby and leave you on your own.

Date services will most likely be needed.

How Long will your Baby Nurse be Needed? How Long will your Baby Nurse be Needed?2 weeks3 weeks4 weeks6 weeksother

Other Time Needed (up to 6 months)

Babies Name

Siblings Names & Ages:

Pets (cat/dog) & Names:

What things would be the most helpful to you while your Baby Nurse is in your home?

Over the next four questions select the following items for order of importance: 1 – Breastfeeding assistance 2 – Getting the baby on a Schedule 3 – Sleep and Recovery for Mommy 4 – Help with meals. ----- Please select the FIRST most important item. Over the next four questions select the following items for order of importance: 1 – Breastfeeding assistance 2 – Getting the baby on a Schedule 3 – Sleep and Recovery for Mommy 4 – Help with meals. ----- Please select the FIRST most important item. Breastfeeding assistance Getting the baby on a Schedule Sleep and Recovery for Mommy Help with meals

SECOND most important item. SECOND most important item. Breastfeeding assistance Getting the baby on a Schedule Sleep and Recovery for Mommy Help with meals

THIRD most important item. THIRD most important item. Breastfeeding assistance Getting the baby on a Schedule Sleep and Recovery for Mommy Help with meals

FOURTH most important item. FOURTH most important item. Breastfeeding assistance Getting the baby on a Schedule Sleep and Recovery for Mommy Help with meals

How Did you find out about Our services? Please be as specific as possible!

Have you ever used a Professional child care provider (Nanny/Baby Nurse etc.) in the past? If so, what was you experience like?

Do you have a housekeeping service? Do you have a housekeeping service? Yes No

How frequently? How frequently? Daily Weekly Every 2 weeks Monthly

Anything else that you want to tell us?

Terms of Service – Your Infant Care Provider will not give medical advice or treatment to baby, mother, or anyone else. We are not qualified to give such advice. However, they will answer your questions according to their opinion from their experience and education in new mother and infant care. Rachel's Infant Care is a Postpartum Recovery Care Placement Agency. We charge a non-refundable placement fee for our placement services. This fee insures you will have a caregiver at the date you requested. If your baby arrives early, or late we still do our best to get your chosen care provider to you within 48 hours of your discharge from the hospital. If your care provider is not available, we will set you up with a care provider that best matches your chosen provider in skill and personality. Travel is invoiced at a rate of $0.55 a mile round trip (to and from your home) OR round-trip airfare plus $100. There is an eight (8) day minimum which you will be charged a per day rate (Call Rachel to find out your per day rate - 770.597.8330) to be paid within 2 days of receiving the invoice. If you are reserving more than 6 weeks of care a deposit will be required to hold your place on your chosen caregiver’s calendar. Your Care Provider is NOT your maid. The Care Provider’s job description can be emailed to your upon request. If you choose to have her do heavy housework like cleaning the bathrooms, you will be charged accordingly. We the parents will not sue the Infant Care Provider or Rachel's Infant Care if an accident occurs while they are in our home. Terms of Service – Your Infant Care Provider will not give medical advice or treatment to baby, mother, or anyone else. We are not qualified to give such advice. However, they will answer your questions according to their opinion from their experience and education in new mother and infant care. Rachel's Infant Care is a Postpartum Recovery Care Placement Agency. We charge a non-refundable placement fee for our placement services. This fee insures you will have a caregiver at the date you requested. If your baby arrives early, or late we still do our best to get your chosen care provider to you within 48 hours of your discharge from the hospital. If your care provider is not available, we will set you up with a care provider that best matches your chosen provider in skill and personality. Travel is invoiced at a rate of $0.55 a mile round trip (to and from your home) OR round-trip airfare plus $100. There is an eight (8) day minimum which you will be charged a per day rate (Call Rachel to find out your per day rate - 770.597.8330) to be paid within 2 days of receiving the invoice. If you are reserving more than 6 weeks of care a deposit will be required to hold your place on your chosen caregiver’s calendar. Your Care Provider is NOT your maid. The Care Provider’s job description can be emailed to your upon request. If you choose to have her do heavy housework like cleaning the bathrooms, you will be charged accordingly. We the parents will not sue the Infant Care Provider or Rachel's Infant Care if an accident occurs while they are in our home. Yes, I agree