Language
English (US)
Spanish (Latin America)
Bx (Re)Birth Doula Services
Mariame Kaba Birth Liberation Fund to Provide No-Cost Doula Services
Email
*
example@example.com
Name
*
First Name
Last Name
How did you hear about this opportunity?
Social Worker
Community Health Worker
Instagram Post
Facebook Post
From a friend
Midwife
Ob/Gyn
Internet Search
Prenatal Clinic
Other
What are your pronouns?
She/Her
He/Him
They/them
Other
Phone Number
*
Format: (000) 000-0000.
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?
*
Name of the Hospital Where You Plan to Give Birth
*
Bellevue Hospital Center
Bronx Lebanon Hospital
Brookdale Hospital Medical Center
Brooklyn Hospital Center - Downtown Campus
Coney Island Hospital
Elmhurst Hospital Center
Flushing Hospital Medical Center
Forest Hills Hospital
Harlem Hospital
Interfaith Medical Center
Jacobi Medical Center
Jamaica Hospital Medical Center
Kings County Hospital Center
Lenox Hill
Lincoln Medical & Mental Health Center
Long Island College Hospital
Long Island Jewish Medical Center
Lutheran Medical Center
Maimonides Medical Center
Metropolitan Hospital Center
Montefiore
Mount Sinai East Hospital
Mount Sinai West - St. Luke's
New York Downtown Hospital
New York Hospital Medical Center of Queens
New York Methodist Hospital
New York Presbyterian Hospital - Allen Hospital
New York Presbyterian Hospital - Columbia Presbyterian Center
New York Presbyterian Hospital - New York Weill Cornell Center
North Central Bronx Hospital
NYU Langone
Queens Hospital Center
Richmond University Medical Center
St Johns Episcopal Hospital so Shore
St. Barnabas Health System
Staten Island University Hosp-North
University Hospital of Brooklyn
Woodhull Medical & Mental Health Center
Wyckoff Heights Medical Center
Not Giving birth in a hospital
Other (outside of the 5 boroughs)
Have not begun receiving prenatal care
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?
*
Do you need financial assistance to pay for doula services?
*
Yes
No
Describe how support from Bx (Re)Birth's Mariame Kaba Birth Liberation Fund will help you achieve any personal goals related to your birth, parenting, or otherwise.
*
Recipients of Bx (Re)Birth's Mariame Kaba Birth Liberation Fund Doula Scholarship are required to complete a childbirth education course. Do you agree to complete a childbirth education course?
*
Yes
No
Recipients of Bx (Re)Birth's Mariame Kaba Birth Liberation Fund Doula Scholarship are expected to complete an evaluation after they give birth and services are completed. Do you agree to complete a post birth evaluation form?
Yes
No
Do you consent to the use of your photo for program reporting purposes and/or promotion of the program to receive more funding?
*
Yes, but I would like to review any photos before they are used
Yes, and I do not need to review any photos selected
No, I do not consent to the use of my photo by Bx (Re)Birth
Not sure
Are you interested in receiving information about free or low cost prenatal yoga and dance classes?
*
Yes
No
Submit
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