Language
English (US)
Spanish (Latin America)
Bx (Re)Birth Doula Services
Intake Form
Email
*
example@example.com
Name
*
First Name
Last Name
What are your pronouns?
She/Her
He/Him
They/them
Other
Phone Number
*
What is the best way to get in contact with you?
Text message
Voice Call
Email
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
YOUR date of birth
*
-
Month
-
Day
Year
Date
Are you black, Indigenous, or a person of color?
*
Black
Indigenous
Non-white
Other
When is your estimated due date?
*
-
Month
-
Day
Year
Date
What number pregnancy is this for you?
Where are you planning to give birth?
*
Hospital
Home
Birthing Center
I don't know.
Which Hospital or Birthing Center do you plan to give birth in?
What Else should we know about your pregnancy?
*
What else should we know about your birth goals?
*
What quality traits would you like your doula to possess?
*
We offer 3 doula packages with the following contents and prices: 1. $1250 (2 prenatals; labor support; and 1 postpartum visit); 2. ($1800 (2 prenatals, labor support and 1 postpartum visit with doulas of 2 yrs. + experience); 3. $2100 (2-3 prenatals, labor support and 2 postpartum visits with doulas of 3 yrs. + experience). Please indicate below which service option you would like.
*
Package 1 (1250)
Package 2 (1800)
Package 3 (2100)
Do you need financial assistance to pay for doula services? **Please answer this question TRUTHFULLY based on your individual and/or family's financial ability.**
*
Yes. I need to use a payment plan.
Yes. I need help paying the full fee.
No.
We are able to subsidize a limited number of birth doula service packages. The value of these services is $1100. We ask everyone to pay a minimum of $500. What amount can you pay?
*
$500
$650
Submit
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