Birth Doula Services Referral Form

Birth Doula Referral Form

Doulas4CT
Full Name*

First NameLast Name
Contact Number*
Please enter a valid phone number.
Email Address*
example@example.com
Home Address*
Primary Language
Estimated Due Date (EDD)

MonthDayYear
Date
Who were you referred by? How did you hear about our free services?
Emergency Contact Name
Emergency Contact Phone Number
Do you give your Doula consent to leave voicemails on the phone number you've provided?

YesNo
Do you give your Doula consent to text the phone number you've provided?

YesToo
How do you identify yourself?

African AmericanAfro- CaribbeanNative American/Alaskan NativeLatin/Spanish speakingAfrican 1st generationAfrican 2nd generation
Are you active TANF

YesNo
Do you have Husky Insurance?

YesNo
Subscriber or Policy Number
Group Number
Number of pregnancies
Number of live births
Marital Status

Single (or never married)MarriedDivorcedWidowed
Has the other parent been involved with the prenatal visits/assessments?

YesNo
Will the other parent be involved with prenatal appointments with Doula?

TYesNoUnsure
Have you created a birth plan?

YesNo
Is there any other close friend or family member that will be providing support?

YesNoUnsure
Have you taken any or planning to take childbirth education classes (not including hospital tour or information provided by your medical provider)?

YesNo
Do you plan to breastfeed?

YEsNoCombo formula and breastfeeding
Have you had prior experience with breastfeeding

YesNo
Are there any health concerns or medical conditions identified by your medical provider e.g., Diabetes, Hypertension, Pre-eclampsia symptoms, AIDS/HIV, Herpes, or other High Risk Factors?

YesNo
If yes, please explain below
If yes, has your medical provider instituted a treatment plan specific to the medical condition?

YesNo
What is your primary reason for choosing a doula?
Are you looking for doula support during labor and delivery?

YesNo
Are you looking for doula support after the baby is born?

YesNo
Would you be able to contribute any costs for doula care?

YesNo
Your signature below provides a release so that the intake coordinator can provide this information to the doula(s) assigned to you. We will not share your information with anyone and will apply confidentiality concerning your health information.
Signature

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Birth Doula Referral Form