Clone of 4th Trimester Arizona – Doula Certification Application 1 Due Mon 11/17

Legal Name*

First NameLast Name

Date of Birth*

MonthDayYear

Email*

Phone*

Area CodePhone Number

Social Security Number*

Residential Address*

Mailing Address

Have you completed the PSI 2-Day Training?*

YesNo

If yes, When?

Are you a community based doula who reflects underserved populations (Black, Indigenous, Latinx)?*

YesNo

Ethnicity*

What Languages do you speak?*

Have you ever held a Doula certification in AZ?*

YesNo

If yes, certification #

Do you hold other professional licenses or certifications in this or any other state?*

YesNo

If yes, List the professional license or certification and the state in which it was issued.

Have you ever had a professional license or certificate suspended, revoked, or had disciplinary action taken against it?*

YesNo

If yes, to the previous question, please provide the following information: 1. The type of action taken against the professional license or certificate, 2.The date of the action and 3. The state or nationally accredited certifying body that issued the action.

An explanation of the disciplinary action, revocation, or suspension:

Are you currently ineligible for licensing or certification in any state because of a license revocation or suspension?*

YesNo

If yes, please list, 1. The type of action taken against the professional license or certificate, 2. The date of ineligibility, and 3. The state or jurisdiction

An explanation of the ineligibility for licensing or certification:

Have you completed high school or do you have a GED?*

YesNo

Education History (Institution / Degree / State/ Date) (High School, College, Doula Education)*

Employment History for the last 5 years (Employer / Position / Address of Employer / Supervisor's Name, Email and Phone / Dates of Employment)*

Please Check the Applicable Fields:

I am a U.S. VeteranI am a U.S. Military Spouse

Which Pathway to Licensure are you applying under?*

Pathway 1- A completed and signed Birth Observation form.• A completed and signed Primary Doula Attestation for three (3) births while serving as the primary doula, including evaluations from the laboring mother and medical provider/licensed midwife.• Completed and signed Doula Competency Attestation form demonstrating at least 30hours of in-person instruction or a combination of in-person and online instruction in core competency topicsPathway 2- A completed and signed Birth Observation form.• A completed and signed Primary Doula Attestation for three (3) births while serving as the primary doula, including evaluations from the laboring mother and medical provider/licensed midwife.• Proof of current certification from a nationally recognized doula organization.Pathway 3- A completed and signed Birth Observation form.• A completed and signed Primary Doula Attestation for three (3) births while serving as the primary doula, including evaluations from the laboring mother and medical provider/licensed midwife.• Completed and signed Doula Competency Attestation form demonstrating community training in non-western doula practices and confirmation of completed core competency training through culturally specific training or education.Pathway 5- If you are an individual who does not otherwise qualify, but has been practicing as a doula in this state for at least five (5) years before September 29, 2021, you may apply by submitting ALL OF THE FOLLOWING:• Proof of current certification from a nationally recognized doula organization. AND• Completed and signed Letters of Recommendation form from health care professionals who have worked with the applicant within the preceding two years who can attest to the applicant’s competency in providing doula services.

Are you a Citizen or National of the United States?*

YesNo

If yes, to the previous question, indicate place of birth: City, State and County or Territory.

Are you able to attend one PSI 2-Day Training and one Perinatal Navigation Training that's required? PSI 2-Day Trainings: 3/11-3/12 (register by 2/25) Perinatal Navigation: March 28 April 23 May 16*

YesNo

I attest that all information submitted as part of this application is true and accurate.

Acknowledgment

I understand that missing items may delay processing.

Signature*

Date*

MonthDayYear