Doula Hub Intake Form
Share your contact and pregnancy details so we can match you with the right doula support.
Contact Information
Full Name
*
First Name
Middle Name
Last Name
Legal Name
Preferred Name
Pronouns
Date of Inquiry
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Best Time to Reach You
Hour Minutes
AM
PM
AM/PM Option
Email
*
example@example.com
Preferred Contact Method
Phone
Text
Email
City
ZIP Code
Partner or Support Person Name
Partner or Support Person Relationship
Contact Safety Preferences
Safe to leave a voicemail
Safe to send a text
Please use email only
Your Pregnancy
Estimated Due Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Weeks Pregnant Today
*
Is This Your First Baby?
*
Yes
No
Number of Previous Births
Are You Expecting Multiples?
*
Yes
No
Not sure
Prenatal Care Provider Name or Practice
Where Do You Plan to Give Birth?
*
Please Select
Hospital
Birth center
Home
Not decided yet
Name of Facility, If Known
Provider Type
Please Select
OB
Midwife
Other
What Kind of Support Are You Looking For?
*
Birth doula support
Postpartum doula support
Both birth and postpartum
Childbirth education
Lactation support
Partner or father support
Perinatal mental health support
Sibling preparation
Not sure yet
Additional Pregnancy Notes
What Matters Most to You
What are you hoping for in this birth? What are you worried about?
*
Is there anything about a previous birth or pregnancy that shapes what you want this time?
Practical Details
You may skip this section entirely. Selecting any help items will not affect the care you receive.
Language(s) spoken at home
Do you need interpretation support?
*
Yes
No
Not sure
Accessibility needs or accommodations
Do you have health insurance?
*
Yes
No
Not sure
Health plan name
Do you have a reliable phone?
*
Yes
No
Sometimes
Do you have reliable internet access?
*
Yes
No
Sometimes
What support might you need?
Getting to appointments
Food or groceries
WIC or SNAP
Housing or rent
Utilities or heat
Baby supplies or equipment
Childcare for older children
Applying for benefits
Employment or leave
Legal help
Mental health support
Someone to talk to
Understanding my insurance
Interpreter at appointments
Nothing right now
For Office Use Only
Date Received
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Received By
*
First Name
Middle Name
Last Name
Consultation Scheduled
Assigned To
First Name
Middle Name
Last Name
Eligibility Verification Requested
Insurance
Income
Residency
Pregnancy Status
Referral
Other
Verification Result
Pending
Verified
Needs Follow-Up
Not Eligible
Other
Outcome
Please Select
Accepted
Waitlisted
Referred Out
Declined
Closed
Other
Notes
Submit
Should be Empty: