Certified Perinatal Community Doula Referral

Certified Perinatal Community Doula Referral

Please take a few minutes to tell us more about you and your preferences for a Certified Perinatal Doula. We will try to meet your accommodations and help you select the best fit doula based on your preferences. Please note you will be added to our electronic portal to maintain accountability and communication between our organization and services referral.
Demographic Information
What is your gender?*

Cis FemaleFemaleCis MaleMaleNon-binaryPrefer not to answer
What is your age range?*

0-1718-2425-3435-4445-5455-6465+
What is your marital status?*

SingleMarriedDivorcedWidowedPrefer not to answerIn a relationship (Partnered)Multi-Partnered Arrangement (Poly or Solo Monogamy)
What is your estimated annual income range?*

$9,999 or less$10,000-$24,999$25,000-$49,999$50,000-$74,999$75,000-$99,999$100,000 or morePrefer Not to Answer
What is your employment status?*

Employed full timeEmployed part timeSelf-employedUnemployedNot looking for a jobHomemakerStudentPrefer not to answer
What is the highest level of education you have completed?*

Less than high schoolHigh schoolSome college / UniversityCollege diploma / CertificateUndergraduate degreeMasters / Graduate degreeDoctoratePrefer not to answerOther
Information and Awareness of Certified Perinatal Doulas
Are you aware as of July 1, 2022 RI Certified Perinatal Doulas are a covered benefit for RI insurance companies?*

YesNoNever heard of itWhat is a doula?
Did you know that only RI Certified Perinatal Doulas are able to take insurance reimbursement in Rhode Island?*

YesNoNever heard of it
Which Rhode Island insurance do you have?*

Neighborhood Health Plan RI (Commercial)Neighborhood Health Plan (Medicaid)United HealthCare (Commercial)United Health Care (Medicaid)Tufts RITogether (Medicaid)Tufts Health (Commercial)Blue Cross Blue Shield of RI (Commercial)Other
Did you have a doula for your previous birth?

NoYesFamily or Partner (Bradley)Other
Reasons for Choosing a Doula/Type of Doula Preferred
Which of the followings would influence your decision to hire a doula?

Black Maternal Health Disparities/MortalityPrior Birth Trauma/TriggerMore or Additional Emotional and Physical SupportTrauma/Trigger/AnxietyOther
Racial Preference?
Racial Preference?
Prefer Black/African American, White, Indigenous
Ethnicity Preference?
Ethnicity Preference?
Prefer Latinx/Hispanic
Lifestyle Preference (Singular, PolyAmorous/Gamy, Single Parent, IVF/IUI, Surrogate )?
Lifestyle Preference?
Prefer PolyAmorous/Gamy, Single Parent, IVF/IUI, Surrogate
Birthing Style Preference?
Birthing Style Preference?
Prefer Any, Natural, etc.
Religion/Spiritual Preference?
Birthing Style Preference?
Prefer Christian, Muslim, Jewish, NonDenominational
Ideal characteristics in your doula:*

ImaginativeSeriousFunnySpiritedSuccessfulCheerfulOutdoorsyIntrovertDaringReliableSophisticatedIntelligentHonestClassyToughOther
Pregnancy/Gestation Related

Question regarding your planned or currently expecting pregnancy
Currently:
Estimated Due Date

MonthDayYear
Date
Birthing Hospital
Type of Provider
Name of Practice and Address
Name of Provider (If Applicable)
General Information
Name

First NameLast Name
Please share your email address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Preferred Method of Contact*

EmailPhone (Text)Phone (Call)Contact through Mahmee Portal
What type of learner are you? (Select all that apply)*

Visual/VideosBooks & LiteratureAudio/PodcastsComputers & ElectronicsTactical/Hands OnHobbies & LeisureRepetitive/RemindersActivities/GamesOnline CommunitiesTasks/Lists/AgendaReference
Anything else you would like us to know?
Should be Empty:

Certified Perinatal Community Doula Referral

Demographic Information

Information and Awareness of Certified Perinatal Doulas

Reasons for Choosing a Doula/Type of Doula Preferred

Pregnancy/Gestation Related

General Information