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! Currently, DDI plans to take 50 clients annually and matching is conducted based on location and availability. At this time, DDI is a solely grant-funded organization that delivers in financially supportive hospitals.*Completion of our application is not a guarantee of matching.*Please Review the eligibility criteria: 1. Must be greater than 16 weeks of gestation. 2. Clients under the age of 18 will need to be approved on a case by case basis.
Name:

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

MonthDayYear
Client Age:
Street Address:

Street Address

Street Address Line 2

CityState / Province

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

Black/African AmericanAsianAmerican Indian/ Alaskan NativeNative Hawaiian/ Other Pacific IslanderMulti-Ethnic/ Multi-RacialOther
Ethnicity (Check all that apply):

HispanicNon-HispanicOther
Primary Language (Check all that apply):

EnglishSpanishOther
Marital Status:

SingleMarriedDivorcedWidowedOther
Level of Education:

Some High SchoolHigh School DiplomaGEDSome CollegeCollege GraduateMaster'sDoctoral Degree (MD, PhD, DO, JD, etc.)Other
Occupation:
Do you identify with one or more of the following? (Check all that apply):

Food InsecurityHave not yet accessed prenatal careHousing InsecurityExperiencing StressExperiencing transportation barriers for medical appointmentsExperienced medical racismNone of the above
How many people reside in your household?

1234 or moreOther
How many people contribute to your house hold income?

1234 or moreOther
Based on your most recent tax filing status, what is your total household income before taxes?

Below $11,000$11,001 - $44,725$44, 726 - $95, 375$95, 376 - $182,100$182,101 - $231,250$231,251 - $578,125$578,126 and up
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?

Yes, confirmed at a medical office/services centerNo, but confirmed at homeNeither of these are trueOther
Prior to pregnancy, how many times has the client given birth?

This will be my first time giving birth1-23-45 or more
If you have given birth before, what was your type of delivery (Check all that apply):

I have not given birthVaginalCesareanVBAC
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)

YesNo
Weeks of Gestation: (16 weeks and 0/7 weeks to 28 and 0/7 weeks)
Due Date:

MonthDayYear
Due Date
Who is your birth-care provider?
How many times have you visited your birth care provider during you pregnancy so far?

01-23-45 or more
Where do you plan to deliver?

UPMC (Lititz)UPMC (Harrisburg)UPMC (York)Other
Method of Payment (Insurer)

MedicaidHighmark WholecareAetnaBluecross BlueshieldKaiser PermanenteHumanaUnited HealthcareUninsuredOther
Do you intend to utilize a birth plan?

YesNoOther
Other than a Doula, who do you plan to have assist you with the birth? (select all that apply)

Partner/SpouseMother/ Mother in LawSisterFriendNo oneOther
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
How did you hear about the Diversifying Doulas Initiative? (Check all that apply)

Social Media (Instagram, Facebook, LinkedIn)Social WorkerBirth ProviderFamily Member/ FriendA DoulaOther
Do you understand that this program requires you to work with a doula from your second trimester until six weeks post delivery?

Yes, I understandNo, I do not understand
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.

Yes, I understandNo, I do not understand
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Diversifying Doulas Initiative Intake Form