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. Our doulas are verified by the RI Certification Board, the authorization body for RI Certified Perinatal Doulas to take insurance. 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
Date of Birth

MonthDayYear
Month Date Year
What is your gender?
What is your age range?
What is your marital status?
What is your estimated annual income range?
What is your employment status?
What is the highest level of education you have completed?

Other
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?
Did you know that only RI Certified Perinatal Doulas are able to take insurance reimbursement in Rhode Island?
Are you a foster parent seeking postpartum doula support?
Which Rhode Island insurance do you have?

Other
Insurance Card Information (Member/Group)
If you do not know, write 000-00
Which Massachusetts insurance do you have?

Other
Insurance Card Information (Member/Group)
Did you have a doula for your previous birth?

Other
Will you need extended postpartum support (beyond the allowable visits)?

Other
Reasons for Choosing a Doula/Type of Doula Preferred

No judgement on any of the selections, want to provide you with the best and most support
Which of the followings would influence your decision to hire a doula?

Other
Are you in need of justice assistance for your pregnancy, birth, or postpartum?

Other
How were you referred to a doula?

Other
Racial Preference?

Rate the level of importance for Racial preference request
Racial Preference?
Prefer Black/African American, White, Indigenous
Ethnicity Preference?

Rate the level of importance for Ethnicity preference request
Ethnicity Preference?
Prefer Latinx/Hispanic
Lifestyle Preference (Singular, PolyAmorous/Gamy, Single Parent, IVF/IUI, Surrogate )?

Rate the level of importance for lifestyle preference request
Lifestyle Preference?
Prefer PolyAmorous/Gamy, Single Parent, IVF/IUI, Surrogate
Birthing Style Preference?

Rate the level of importance for birthing style preference request
Birthing Style Preference?
Prefer Any, Natural, etc.
Religion/Spiritual Preference?

Rate the level of importance for spiritual preference request
Religion/Spiritual Style Preference?
Prefer Christian, Muslim, Jewish, NonDenominational
Ideal characteristics in your doula:

Other
Pregnancy/Gestation Related

Question regarding your planned or currently expecting pregnancy
**TRIGGER warning** Are you actively:
Currently:
Currently:
Postpartum Related
Estimated Due Date

MonthDayYear
Date
Baby's Birth Date

MonthDayYear
Date
Is this is a declared high risk pregnancy by provider?
Hypertension, Preeclampsia, Gestational Diabetes, Chronic Health Condition
Have you been informed or provided an induction protocol?
Provider has stated an imminent induction possibility or procedure
Birthing Hospital
Women and Infants Hospital, Kent Hospital, Landmark Medical Center, South County Hospital, Newport Hospital (Massachusetts Hospitals)
Home Birth Practice
Home Birth is available in Rhode Island - not covered by insurance. www.rhodeislandmidwives.com
Type of Provider
Nurse Midwives provided hospital births
Practice Office
Name of Practice and Address
Name of Provider/Doctor (If Applicable)
Name of Pediatrician(If Applicable)
Newborn will need a pediatrician to discharge them from the hospital
General Information
Name

First NameLast Name
Partner/Father/Spouse

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.Format: (000) 000-0000.
Preferred Method of Contact
What type of learner are you? (Select all that apply)
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