Pregnant Person's Information:
First Name
*
Last Name
*
Cell Phone Number
*
E-mail
*
Preferred Pronoun
she/her
he/him
they/them
Partner's Information
(if you have one)
:
First Name
Last Name
Cell Phone Number
E-mail
Preferred Pronoun
she/her
he/him
they/them
Street Address
Apartment or Unit #
City
*
Zip Code
*
Your Home Phone Number (if you have one)
Due Date
*
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2021
2020
Year
I want/need
*
Virtual Childbirth Education
A Virtual Birth Doula
An In-Person Doula (post quarantine OR if you have no partner)
A Postpartum Doula
A Birth and a Postpartum Doula
Postpartum Doula Needs
Days only
Nights only
24 hour care
A few days a week
Every day
Help for the first few weeks
Help for the first three months
Budget for Birth Doula
*
600+ births ($2800-$3500)
450-600 births ($2550-$3150)
250-500 births ($2300-$2900)
150-300 births ($2050-$2650)
100-200 births ($1800-$2400)
75-150 births ($1550-$2150)
25-100 births ($1300-$1900)
10-50 births ($1050-$1650)
0-15 births ($800-$1400)
Virtual Support Options (All options are fully explained on What Does a Doula Cost - link provided at the top of this page)
Virtual Interview - FREE (15-20 minutes)
Informational Interview/Tips - $100 (90 minutes)
Informational Interview/Tips plus packet - $120 (90 minutes)
Private Childbirth Preparation Series (5-6 hours/$500)
Group Childbirth Preparation Series (bring a pregnant friend $50 discount each)
Individual Childbirth Preparation Class ($200/each)
Limited Virtual Birth Support ($1,000 following full series)
Limited Virtual Birth Support ($1,500 if series not taken)
Unlimited Virtual Support ($2,000 following full series)
Unlimited Virtual Birth Support ($2,500 if series not taken)
In Person Birth Support (post-quarantine) $3,200 with discounts available
Name of Hospital (or homebirth)
*
other or undecided
Anaheim Memorial Hospital
Arcadia Methodist
California Medical Center
Cedars-Sinai Medical Center
Encino-Tarzana Hospital
Foothill Presbyterian
Glendale Adventist Medical Center
Glendale Memorial
Good Samaritan
Hoag Hospital
Homebirth
Huntington Memorial Hospital
Kaiser Anaheim
Kaiser Baldwin Park
Kaiser Cadillac
Kaiser Panorama City
Kaiser Sunset
Kaiser Woodland Hills
Little Company of Mary
Loma Linda University Medical Center
Long Beach Memorial
Los Robles
Northridge Hospital
Providence Tarzana Medical Center
Ronald Reagan UCLA
San Gabriel Valley Medical Center
Santa Monica Hospital
Santa Monica/UCLA
St John's
St. Joseph Medical Center Burbank
St. Jude's Hospital, Fullerton
St. Joseph Hospital Orange
Tarzana-Encino
Torrance Memorial Hospital
UCLA Ronald Reagan Westwood
Verdugo Hills Hospital
White Memorial
Whittier Presbyterian
Name of Hospital if not on list above
Name of Doctor or Midwife (alphabetical by last name)
*
Choose from this list or fill in below
Undecided - need help with choice
Christina Adberg
John Aiken
Thais Aliabadi
Carol Archie
Elizabeth Bachner
Patrick Baggot
Peyman Banooni
Bonnie Beaver
Ohad Ben-Yehuda
Doron Blumenfeld
Yvonne Bohn
Violet Boodaghians
Pam Boyer
Rebecca Brown
Conwell Carter
Shirley Chan
Shirley Chen
Anthony Chin
Tony Chin
Cindy Chou
Susan Cohen
Christine Collins
Ruth Cousineau
Christopher Cox
Paul Crane
Olivia Crookes
James Danielzadeh
Mary Day
Allison Devine
Lorrie Dubow
Mark Dwight
John Edwards
Allen Enten
Stuart Fischbein
Felicia Forrest
Suzanne Gilberg-Lenz
Susan Gill
Jay Goldberg
Allyson Gonzales
Seymour Gorelick
Shaun Grady
Brent Gray
Paul Hackmeyer
Theodric Hendrix
Allison Hill
LaTanya Hines
Ann Hofstadter
Vanessa Isiaka
Bryan Jick
Beth Julian-Wang
Bobby Katz
Linda Katz
Joel Kessler
Frederick Kohn
Karen Kornreich
Selena Lantry
Karen Lapesarde
Lily Lee
Eleanor Leung
Joseph Li
Edward Liu
Nathana Lurvey
Howard Mandell
Lisa Masterson
George Matsuda
Bonnie Maxfield
Paula McAllister
Marcia McCulley
Claudette McKenzie
Jose Medrano
Edward Merchant
UCLA Midwife Group
Susan Minich
Michael Mitri
James Moran
Lillian Morris
Robert Morrison
Toni Morrissey
Karyn Morse
Lisa Nelson
Angela Nishio
Terre Osterkamp
Maria Ottavi
Alane Park
Jennifer Park
Kerri Parks
Christopher Pearson
Rebecca Perlow
Zoya Preys
Sharon Pushkin
Stephen Rabin
Kim Reyes
Donna Richey
Elena Rodriguez
Sheryl Ross
Jason Rothbart
Jessica Schneider
Scott Serden
Ed Sigall
Emily Sikking
Laura Sirott
Amy Stenson
Leslie Stewart
Anita Sumen
Denise Sur
Naomi Suriel
Joana Tamayo
Frances Teng
Bo Thordarson
Jacqueline Trejo
Susan Tritt
Ann Trudell
Henry Tsai
Mae Ushigome
Karen Valenton
Taz Varkey
Ayanna Walden
George Weinberger
Peter Weiss
Jonathan Wheeler
Julia Willner
Michaelyn Wilson
Sue Wolcott
Kay Wood
Ronald Woodard
Ronald Wu
Sarah Yamaguchi
Alice Yun
Alice Yung
Angelica Zaid
Name of Doctor or Midwife if not on list above
I am expecting
*
A Boy
A Girl
Boy/Boy twins
Girl/Girl twins
Boy/Girl twins
Don't Know
This birth will be
*
My First Birth
My Second Birth
A VBAC
Other
Best Day to Meet
*
Weekends
Saturdays only
Sundays only
Weekdays
Best Time to Meet
*
Mornings
Afternoons
Evenings
Preferred Place to Meet
*
Meeting Place
Virtual Interview - FREE (20-30 minutes)
Virtual Introductory Class/Tips - $100 (90 minutes)
Virtual Introductory Class/Tips plus packet - $120 (90 minutes)
B*E*S*T Office in Alhambra (free) when it's safe again
Your Home ($150) when it's safe again
Public Place ($150) when it's safe again
Referred by:
Please Provide Name
Google search
Yahoo search
Yelp search
Yelp Ad
Other search (please provide name below)
Another doula (please provide name below)
A former client (please provide name below)
Someone else (please provide name below)
Another website (please provide name below)
Questions, Comments, Concerns, Reason for Looking for a Doula or referral source
Verification
*
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