Diversifying Doulas Initiative: Intake Form

Diversifying Doulas Initiative Intake Form

Navigating pregnancy can bring a range of emotions as you prepare for the transformative journey of childbirth and parenthood. The Diversifying Doulas Initiative offers your family comprehensive care and support during this special time through subsidized and reduced-cost services. Completion of our intake form is not a guarantee of matching with a doula. Please review the eligibility criteria: 1. Must be greater than 16 weeks of gestation. 2. Must reside in Pennsylvania. 3. Must identify as BIPOC (Black, Indigenous, and people of color).
Name:

First NameLast Name
Phone Number (Include Area Code):
Format: (000) 000-0000.
E-mail:
example@example.com
Date of Birth:

MonthDayYear
Your Age:
Street Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Race (Check all that apply):

Other
Ethnicity (Check all that apply):

Other
Primary Language (Check all that apply):

Other
Marital Status:

Other
Level of Education:

Other
Occupation:
Do you identify with one or more of the following? (Check all that apply):
How many people reside in your household?

Other
How many people contribute to your house hold income?

Other
Based on your most recent tax filing status, what is your total household income before taxes?
Have you had your pregnancy confirmed by a test done at a medical office? If not, have you gotten at least one positive home test?

Other
Prior to this pregnancy, how many times have you given birth?
If you have given birth before, what was your type of delivery (Check all that apply):
Did you receive your first prenatal care visit in the first trimester? ( First trimester is defined as zero and up to 14 weeks and 0 days)
Weeks of Gestation:
Due Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDue Date
Who is your birth-care provider?
How many times have you visited your birth care provider during you pregnancy so far?
Where do you plan to deliver?

Other
Do you currently have health insurance or medical coverage?
If yes, what type of medical coverage do you have?
Who is your medical insurance provider?

Other
If selected "Other", please list your insurance provider here.
Do you intend to utilize a birth plan?
Other than a Doula, who do you plan to have assist you with the birth? (select all that apply)

Other
Explain any complications you have had with this pregnancy, any restrictions your caregiver has given you, and any medications you are currently taking.
Are you aware of what a Doula is? If yes, please explain
Please share any specific preferences and/or relevant information to assist in your doula pairing.
How did you hear about the Diversifying Doulas Initiative? (Check all that apply)

Other
Do you understand that this program requires you to work with a doula from your second trimester until twelve (12) weeks postpartum?
Acknowledgement Statement: I acknowledge that I have answered this intake form fully and truthfully. If any false information is learned, I understand that I may no longer be eligible for a doula through DDI. The information being collected from this form will be utilized for any upcoming research and/or presentations for DDI.
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Diversifying Doulas Initiative Intake Form