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Doula Client Intake Form
All information shared will be kept private and secure in HIPAA-compliant software.
Legal Name (Must match insurance ID)
*
First Name
Last Name
What are your pronouns?
she/her
he/him
they/them
Other
Date of Birth
*
-
Year
-
Month
Day
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Preferred Contact Method
Phone
Email
Text
Date of your Last Menstrual Period
*
-
Year
-
Month
Day
Date
Expected Delivery Date
*
-
Year
-
Month
Day
Date
What race/ethnicity best describes you?
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
Latino or Hispanic
White
I prefer not to answer
Arab/Middle Eastern
Other
Emergency Contact Information
Name
*
First Name
Last Name
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Doula Preferences
Doula support is based on availability so we will do our very best to match you with a doula that meets your unique needs. All of BWOCC doulas are trained in reproductive justice framework and provide care through a trauma-informed, culturally competent lens.
If you have already connected with a doula, please enter their name here.
Do you need doula support in a language other than English?
Yes
No
Other
What kind of doula are you looking for? (speaks a specific language, cultural, spiritual, or religions needs, experience supporting people with disabilities, LGBTQIA+ friendly, etc)
Is there anything else you would like to share with us? Are there any things you'd like us to know about your needs?
Insurance Information
Primary Insurance Provider (Ex: CA Medi-Cal/State Medicaid Card)
*
Primary Insurance ID Number
*
Do you have secondary insurance? If yes, please upload all your insurance cards below)
Yes
No
Secondary Insurance Provider (Ex: Kaiser, Healthnet, Employer insurance, etc)
*
Secondary Insurance ID Number
*
Upload a picture of your insurance card(s), front and back.
*
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Permission to share information
By submitting this form you agree to share your protected health information with Birthworkers of Color Collective and the secure, HIPAA-compliant software programs we use to manage your care.
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