Referral Form for Doula Services in Herkimer County
This form is the first step to match a Herkimer County pregnant resident to a birth doula from Herkimer County Public Health. There is no cost to access our doula services. Please answer the questions below. Thank you!
1. Referral Source
Is this a self-referral or person referring someone?
*
Self-referral (start at question #2)
I am referring someone (start at question 1a.)
1a. If you are referring someone, please provide referral information below:
Name (leave blank if self-referred)
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Relationship to referral
Please Select
Midwife
Community Organization
Physician
Other Healthcare Worker
Family Member
Friend
Other
2. Referral Information
Name
*
First Name
Last Name
DOB
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
*
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Race
*
White
Asian
African American
Native Hawaiian or Pacific Islander
American Indian or Alaskan Native
Hispanic
Non-Hispanic
Primary Language
*
Expected Due Date
*
-
Month
-
Day
Year
Date
Name of OBGYN
Name of Midwife (If applicable)
Planned Delivery Hospital or Birthing Location
*
Is there a specific doula from our organization you would like to request?
*
Yes
No
If you answered "Yes", please provide the partnership doula's name below:
First Name
Last Name
Reason(s) you are interested in working with a doula?
*
I cannot afford a doula on my own.
My partner/family are looking for extra support during pregnancy and birth.
I have had a negative experience in a previous pregnancy.
I am interested in what other pregnancy and birth care options are available in my community.
Other
How di you hear about our doula services?
*
Please Select
Family/Friend
Physician/OBGYN
Midwife
Facebook
Instagram
Herkimer County Website
Community Organization
Other
Submit
Should be Empty: