Provider Referral for Doula Services

Provider Referral for Doula Services

This form is HIPAA-compliant and secure. Submissions are encrypted and shared only with The Doula Lab and Virtuous Doula Training Academy (VDTA) staff for doula matching and care coordination. Please include only the minimum necessary patient information.
Referring Provider Information
Provider/Staff Full Name

First NameLast Name
Provider Role
Provider Office/Practice Name
Practice Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Provider Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Practice Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Provider Email Address
example@example.com
Patient Information (Minimum Necessary)
Patient First Name
Patient Last Name
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Patient Preferred Contact Method
Patient Contact Information (Phone or Email)
Referral Details
Referral Program
Estimated Due Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current Gestational Age in Weeks
Planned Delivery Hospital
If Other, please write in the hospital name
Pregnancy Risk Level
Insurance Information
Insurance information is used only to confirm coverage for doula services. Families in the VDTA No-Cost Doula Program are never billed.
Member / Subscriber ID
Group Number
Is the patient the primary policyholder?
Policyholder Full Name
Policyholder Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Upload Insurance Card (front and back)

Cancelof
Insurance Type
Plan Name
Reason for Referral
Requested Doula Services

Other
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?
Additional psychosocial factors the doula team should know (optional)
Additional Information (Minimum Necessary)
Additional Comments (minimum necessary for referral)
Consent & Acknowledgement
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.
Referring Provider Signature
Date of Referral

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
This form is intended for use by healthcare providers and provider office staff. For questions, contact The Doula Lab.
Should be Empty:

Provider Referral for Doula Services

Referring Provider Information

Patient Information (Minimum Necessary)

Referral Details

Insurance Information

Social Determinants of Health (SDOH) Screening

Additional Information (Minimum Necessary)

Consent & Acknowledgement