Get Doula Support

1
Client Email* This field is required.Please provide the email address for the individual seeing doula support services so that we can contact them.
example@example.com
2
Please provide the names of 2 to 3 doulas you're interested in interviewing. If you have no preference, please enter "No Preference."Review Our Doulas (https://communitydoulaalliance.com/doulas) for a list of names.
3
Client Name* This field is required.
First Name
Last Name
4
Client Pronouns
5
Client Birth Date* This field is required.When were you born?
Date
Month
Day
Year
6
How many weeks pregnant are you?* This field is required.You must be between 10-32 weeks to qualify for our program
Huge
Large
Normal
Small
Ok
Ok
7
Estimated Due Date * This field is required.You must be between 10-32 weeks to qualify for our program.
Date
Month
Day
Year
8
Client Phone Number* This field is required.Best phone number to reach tou via phone or text.
Please enter a valid phone number.
9
Preferred Method of Contact* This field is required.Please select 1 or any number of methods that apply.
Email
Text
Phone
Virtual Call
10
Agreement to text/SMS messaging* This field is required.At Community Doula Alliance, we prioritize your privacy and are committed to protecting your personal health information. With your permission, our team members can communicate with you via text message for appointment reminders, scheduling, and relevant updates about your care. Please note that while we take steps to protect your information, text messaging may not be fully secure. By checking the box below, you agree to receive text messages from Community Doula Alliance and its team members for communication regarding your care. You can opt out of text messaging at any time by letting us know.
11
Client Address, City, State & Zip* This field is required.
12
Do you identify as part of any of the following communities? If the community you identify with is not list, please provide the information in "Other."
Afro-Latino/a/x
Asian (Filipino/a/x, Chinese, Vietnamese, Japanese)
Black/African-American
Indigenous
Latino/a/x
Pacific Islander (Polynesian/Melanesian/Micronesian)
Other
13
Preferred Language* This field is required.
English
Spanish
Other
14
Do you need interpretive services
Yes
No
15
Secondary Contact Name
First Name
Last Name
16
Secondary Contact Person Pronouns
17
Secondary Contact Person Phone Number
Please enter a valid phone number.
18
Secondary Contact Person Email
example@example.com
19
Client Address, City, State & Zip (if different from client)
20
Where is your birth location?* This field is required.Select hospital, birth center or home birth option in dropdown menu
Please Select
Please Select
Providence Newberg
Providence Portland
Providence St. Vincent
Legacy Randall
Legacy Good Samaritan
Legacy Meridian Park
Legacy Mount Hood
Legacy Silverton
OHSU Marquam
OHSU Hillsboro
OHSU Adventist
Kaiser Sunnyside
Kaiser Westside
Alma Midwifery
Canyon Medical Center
Andaluz Midwifery
Home Birth
21
Any other children in the home? If yes, please provide names and ages.
22
What is your childcare plan during your birth?* This field is required.
23
Any pets? If yes, please provide type and number of pets.
24
What is your pet care plan during your birth?
25
In addition to your doula, who will be attending your birth?
26
How did you hear about the Diverse Doula Project of Community Doula Alliance?* This field is required.
Please Select
Please Select
Self- Referral
Family/Friend
Healthcare Provider
Clinic Referral
Community Based Organization
Word of Mouth
Internet Search
Social Media
27
If you were referred by a Community Based Organization, Medicaid, Clinic, or Healthcare Provider please provide the name and contact information.
28
Please provide your Insurance Status and Carrier below:* This field is required.
Please Select
Please Select
OHP Open Card
CareOregon
PacificSource Community Solutions
Trillium Community Health Plan
Yamhill Community Care Organization
I have Private Insurance
I will be paying out-of-pocket
29
Insurance Member ID #* This field is required.This number is needed for OHP Member Benefits verification. If you have Private Insurance or will be paying out-of-pocket put "n/a".
30
Additional Comments or Questions
Should be Empty: