ARPA - ENT Doula Request Client Form

E.N.T. Doula Request Form - Bridgeport Doula Project
This is a Virtual Doula Project. By completing this form, you agree to being referred to a Earth's Natural Touch: Birth Care & Beyond Doula funded by Bridgeport Prospers (ARPA). You also agree to fully participate in allowing the Doulas to support you through your pregnancy and immediate postpartum period (2 weeks postpartum) by receiving scheduled calls and keeping the lines of communication open. To get to know who are we are you can visit our website at www.earthsnaturaltouch.com to see our Featured Doulas.*

Yes
Are you requesting Virtual or In-Person Support? (Please note that there is a fee for In-Person Support)*

VirtualIn-Person (If you are requesting in-person support in addition to the free virtual support you're already receiving, there will be a fee of $700 due by your 35th week gestation. In-person support is based on availability and is not guaranteed)
Are you requesting Virtual or In-Person Support? (Please note that there is a fee for In-Person Support)

VirtualIn-Person (If you are requesting in-person support in addition to the free virtual support you're already receiving, there will be a fee of $700 due by your 35th week gestation. In-person support is based on availability and is not guaranteed)
Your First Name and Last Initial
Your Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Estimated Due Date

MonthDayYear
Date
Weeks Gestation*
Your Phone Number*
Please enter a valid phone number.
Your Email Address*
example@example.com
Do you have access to communicate through (check all that apply):*

PhoneTextEmailVideo Chat/Zoom/Google Meet, etc.
Insurance (Multiple Choice):*

MedicaidPrivate Insurance (please specify below)Uninsured
Name of Insurance*
Race/Ethnicity client identifies as:*
Does the client speak English? If not, what language do they speak? *
Level of Education (check all that apply):*

Less than 4 years of High SchoolHigh School Graduate/GEDTrade SchoolSome CollegeCollege GraduateAdvance College Degrees or Enrollment
NOTES regarding education
Number of Previous Pregnancies*
Number of Living Children*
Ages of Living Children*
Did previous births result in vaginal or cesarean deliveries?
Preferred Feeding Method for Current Child:*

BreastfeedingFormulaCombination of Both
If you have previous breastfeeding experience, please explain.
Partner/Family Support Present?*

YesNo
Do you have any of the following high risk issues? (check all that apply):*

HIV/AIDSOther STIsSmokingAlcohol AbuseIllicit Drug AbuseDepressionOther Mental Health ProblemsDomestic ViolenceTeen PregnancyOver age 35Group B StrepHomelessnessOverweight/Obesity/UnderweightHypertensionDiabetesAsthmaPeriodontal InfectionCurrent Bacteria Vaginosis or UTIFamily History of Breast CancerPrevious Fetal Death, Infant DeathPrevious Pregnancy < 18 monthsHistory of Complicated or High Risk PregnancyNo Support Person PresentDiagnosis of Intellectual DisabilitiesNone of the Above
Do you have any other condition or history of a condition not listed above? *
Do you have any concerns about your pregnancy and postpartum period?*
Signature*

Clear
Date*

MonthDayYear
Date
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E.N.T. Doula Request Form - Bridgeport Doula Project