Doula Contractor Application

Doula Contractor Application

Apply for the independent-contractor doula position by providing your details and the required documentation. This is a 1099 independent contractor role, not an employment (W-2) position. As an independent contractor, you will not be eligible for employee benefits, including but not limited to health insurance, paid time off, workers’ compensation, or unemployment benefits. Sereni Postnatal Retreat, Inc. will provide services to support your independent practice, such as client matching, billing, and administrative support.
Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Full Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Demographics (please select all that apply)

Other
Resume Upload

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Counties You Service

Other
Areas within the county you serve
Medicaid ID Number (for verification, if applicable)
NPI Number (for verification, if applicable)
Upload Valid Adult & Infant CPR Certification

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Upload Doula Training Certification

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Upload Professional Liability Insurance

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How many years have you practiced as a doula?
Voluntary Self-Identification for Government Reporting Purposes

Optional and for government reporting purposes only.
Race/Ethnicity (Optional)

Other
Gender identity (Optional)
Veteran status (Optional)
Voluntary Self-Identification of Disability

Optional and not required.
Do you identify as a person with a disability?
Additional information (optional)
Should be Empty:

Doula Contractor Application

Voluntary Self-Identification for Government Reporting Purposes

Voluntary Self-Identification of Disability