• Provider Referral for Doula Services

    Complete this referral form with only the minimum necessary patient information for doula support.

  • Referring Provider Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Patient Information (Minimum Necessary)

  • Patient Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Patient Preferred Contact Method
  • Estimated Due Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Referral Details

  • I confirm the patient has been informed of this referral to The Doula Lab and consents to The Doula Lab contacting them directly to coordinate doula services.*
  • I confirm this referral includes only the minimum necessary health information for doula matching and care coordination.*
  • Date of Referral*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Requested Doula Services*

  • Additional Information (Minimum Necessary)

  • Consent & Acknowledgement

  • This form is intended for use by healthcare providers and provider office staff. For questions, contact The Doula Lab.

  • Social Determinants of Health (SDOH) Screening

    The following helps us match the patient with the right doula and connect them to additional support. Answer based on what the patient has shared, or mark Unsure if not known.
  • Does the patient have stable, safe housing?*
  • Any concerns about the patient's consistent access to food?*
  • Does the patient have reliable transportation to appointments?*
  • Any concerns about the patient's ability to afford care-related costs?*
  • Does the patient have a support person available?*
  • Any safety concerns at home the doula team should be aware of?*
  • Should be Empty: