Request a Doula: Birth Equity Fund

Shades of Motherhood Network Request a Doula Intake Form
Welcome to the SOMN Doula Fund
We are honored to support you and your family through The Shades of Motherhood Network (SOMN) Doula Fund Program.
Our mission is to ensure Black, Brown, and underserved families have access to culturally responsive care, advocacy, education, and support throughout pregnancy, birth, postpartum, and family wellness. Through this program, families may receive doula and family support services at no cost.
This form helps us learn more about your needs so we can connect you with the best support team and services for your journey
About the SOMN Doula Fund
The SOMN Doula Fund was created to remove barriers to care and increase access to support services for families in our community.
- If you have Medicaid, eligible services may be billed through Medicaid.
- If you do not have Medicaid, services may be covered through the SOMN Fund.
- All approved services are provided at no cost to participating families.
We believe every family deserves support, advocacy, education, and compassionate care throughout their journey.
Thank you for allowing us to walk alongside your family.
Family Details
Were you referred to Shades of Motherhood Network?
If yes, who referred you?
Full Name

First NameMiddle NameLast Name
Pronouns
Date of Birth

MonthDayYear
Date
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Method of Communication

Other
Can Shades of Motherhood Network send text message updates regarding your care, appointments, and resources?
What is your Ethnicity?

Other
What language(s) do you speak or prefer for care?
2. Household and Family Information
Who are the primary support people in your life during this pregnancy or postpartum season?
Number of adults in your household
Number of children in your household
Children’s Ages
Child #1 Age, Child #2 Age, Child #3 Age, Child #4 Age, and other children/ages
Would you like to add a partner, coparent, emergency support person, or other contact?
Added Persons Full Name

First NameMiddle NameLast Name
Relationship to You
Added Persons Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Added Persons Email Address
example@example.com
Will this person be actively involved in your care?
What best describes your current situation?

Other
3. Birth and Health Information

Social Determinants & Support Systems
Why This Section Matters
A mother’s health is shaped by more than medical care alone. Factors such as housing, food access, transportation, emotional support, stress, and past birth experiences can directly affect pregnancy, postpartum recovery, mental health, and overall family wellness.
Understanding these social and life experiences helps our Family Navigator team provide culturally responsive care, connect families to resources earlier, reduce barriers to care, and support healthier outcomes for parents and babies.
This section helps us identify areas where additional support, education, advocacy, or community resources may be helpful for your family.
Estimated Due Date

MonthDayYear
Date
If postpartum, delivery date

MonthDayYear
Date
Where do you plan to give birth, or where did you give birth?

Other
Name of hospital, birth center, or provider if known
Are there any medical, emotional, spiritual, or cultural concerns you would like your doula team to be aware of?
Have you experienced any of the following? Check all that apply.

Other
If you are pregnant and have children, are you need childcare support during delivery?
Doula and Wellness Support Requested
What Is a Doula?
A doula is a trained support professional who provides emotional, physical, educational, and advocacy support to individuals and families during pregnancy, birth, postpartum, and parenting journeys.
Doulas do not replace medical providers. Instead, they work alongside families to encourage education, culturally responsive care, and resource connection to help improve maternal health and family wellness outcomes.
Research shows doula support can help:
- Reduce stress during pregnancy and birth
- Increase confidence and education for families
- Improve birth experiences
- Support breastfeeding and postpartum recovery
- Help families navigate healthcare systems and community resources
- Improve maternal mental health and wellness
Types of Support Available
Doula Community Health Worker
Provides community-based support, resource navigation, health education, advocacy, care coordination, and connection to community services that support family wellness.
Birth Doula
Provides emotional, physical, and educational support during pregnancy, labor, and birth. Birth doulas help families prepare for labor, understand birth options, and feel supported during delivery.
Postpartum Doula
Supports families after birth by helping with recovery, newborn care education, feeding support, emotional wellness, rest, and adjustment during the postpartum period.
Full Spectrum Doula
Provides support across all reproductive experiences, including pregnancy, birth, postpartum, fertility journeys, pregnancy loss, abortion support, and family planning.
Father & Family Navigator
Provides support specifically for fathers, partners, and family members by helping strengthen communication, parenting support, advocacy, emotional wellness, and access to community resources for the entire family unit.
Do you have an SOMN Doula you would Like to work with
If Yes, what's the SOMN Doulas name?
What services are you currently seeking support with? Check all that apply.

Other
Do you currently have any of the following? Check all that apply.

Other
What qualities are most important to you in a doula?
What are your top three needs right now?
Are you interested in Joining any of these other programs?
Billing Information (Note you will never be charged for these services this just is for SOMN Staff)
About Billing & Coverage
At The Shades of Motherhood Network, all services are provided at no cost to the families we serve.
If you currently have Medicaid coverage, we will bill Medicaid for eligible services.
If you do not have Medicaid, your services may be covered through the SOMN Fund to ensure your family still receives support and care.
Our goal is to remove barriers and make sure every family has access to culturally responsive support regardless of insurance status.
Please Select One:
I Do Not Have Medicaid Coverage
I Have Medicaid coverage
This does not pertain to me*
Since Medicaid is selected:
Please provide the following:
- Medicaid Provider/Insurance Plan: Type a label
- Medicaid ID Number:
- Name of Primary Insurance Holder: First Name Last Name
Upload Medicaid Insurance Card (Front & Back)

Cancelof
Confirmation and Consent
Certification
I certify that the information provided on this form is accurate to the best of my knowledge.
Your Initials: Initials here
Consent to Communication
I give Shades of Motherhood Network permission to contact me using the communication methods I selected above regarding care, appointments, support, and resources.
Yes No
Data Use Consent
I understand that my information may be used for care coordination, resource support, and internal program reporting. Any shared reporting will not include my personal identifying information unless I give written permission.
Yes No
Typed or Printed Name:
First Name Last Name
Signature
Date signed

MonthDayYear
Date
Should be Empty:

Shades of Motherhood Network Request a Doula Intake Form

Family Details

2. Household and Family Information

3. Birth and Health Information

Doula and Wellness Support Requested

Billing Information (Note you will never be charged for these services this just is for SOMN Staff)

Confirmation and Consent