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Registration Form
Full Name
*
First Name
Last Name
Nickname/Preferred Name
What is your date of birth?
*
Month/Day/Year (Full)
Partner/Spouse Full Name
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
Best way to reach you:
Phone/Email/Text
Which services are you interested in?
*
Please Select
Childbirth Education Series
Chocolate Milk Cafe (Monthly Lactation/Breastfeeding)
Easy Access Clinic Services (Early Prenatal)
Easy Access Clinic Services (Early Postpartum)
Doula Referral Network
Hold down CTRL to select more than one option.
Which classes do you want to register for this month?
*
Please Select
Pregnancy
Birth
Postpartum
Newborn
Lactation
NICU
Fatherhood
Comfort Measures & Pain Management
Homebirth*
Babywearing*
Cloth Diapering*
Hold down CTRL to select more than one option.
What is your estimated due date or babies' date of birth
*
Month/Day/Year (Full)
Are you interested in doula services?
Yes/No/I want to learn more
Is this form being filled by a provider or case management?
Please Select
Provider Office
Provider Office - Community Health Worker
Case Management (Provider)
Case Management (Birthing Hospital)
Case Management (Insurance Company)
Social Services Agency
Family Home Visiting Program
No
If yes, would like us to connect with you regarding a follow up, please provide your name and contact information
We will notify you we have received your referral request.
How do you identify your gender?
*
Cis Female
Cis Male
Female
Male
Non-Binary
Prefer not to answer
What is your age range?
*
0-17
18-24
25-34
35-44
45-54
How do you racially self-identify?
*
African American
Asian
Black
Indigenous
Native/Indigenous North American
Native/Indigenous South American
Pacific Islander
White
How do you ethnically self-identify?
African
Asian
Caribbean
Indigenous
Prefer Not to Answer
What is your current marital status?
*
Single
Married
Legally Separated
Partnered
In a Relationship (Non-Legal)
Common Law Marriage Arrangement
Divorced
Widowed
Other
What is your estimated annual income?
$9,999 or less
$10,000 - $19,999
$20,000 - $29, 999
$30, 000 - $39, 999
$40, 000 - $49, 999
$50, 000 - $59, 999
$60, 000 - $69, 999
$70, 000 - $79, 999
$80, 000 - $89, 999
$90, 000 or more
What is your current employment status?
*
Employed Full-Time
Self-Employed
Employed Part-Time
Actively Looking for Work
Full Time Homemaker
Student
Unemployed
Unable To Work
Other
What is your highest level of education?
*
High School Diploma/GED
Some College/University
Currently in College/University
Currently in Certification Program
Associates Degree
Bachelors Degree
Masters Degree
Doctorate Degree
Other
Which Rhode Island insurance do you have?
*
Neighborhood Health Plan of RI - Commercial
Neighborhood Health Plan of RI - Medicaid
Blue Cross Blue Shield of RI
United Health Care - Commercial
United Health Care - Medicaid
TuftsRI Together - Medicaid
Tufts Health - Commercial
Aetna (CVS Employee Benefit)
UHC UMR
Other
Member Number
*
Write N/A if not applicable
Group Number
*
Write N/A if not applicable
What Massachusetts insurance do you have?
Member Number
Copy of Insurance Card (Front)
Browse Files
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Choose a file
Cancel
of
Copy of Insurance Card (Back)
Browse Files
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Choose a file
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of
How were you referred to us?
Provider Office
Friend/Family Member
Advertisement (Flyer)
Advertisement (Social Media)
Self Referral
Is there anything else you would like us to know?
We appreciate you sharing your needs with us to better help you. Please note any food allergies here.
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