1. Doula Affiliation Application

Doula Affiliation Application

Bloom Baby Doulas (Bloom Baby LLC) is a Full Spectrum Doula Referral Agency serving New Jersey and the New York Metro Area. Our expert team helps connect families with Doulas that best match their unique needs, preferences, and budget. All of our affiliated Doulas act as Independent Contractors and accept work at will, without exclusivity agreements. We appreciate your interest in joining our team! Before you proceed with this application, please confirm the following.
Do you live in/serve clients in New Jersey and/or the New York Metro Area?*

YesNo
We appreciate your interest, but it seems our areas of service are not aligned at this time.

If you are considering relocating to this area and/or looking to provide services here on a regular basis, please feel free to go back and complete the application accordingly.

Thank you!

Thank you for confirming! Please help us learn more about you and the services you provide.
Important:

To complete this application you will need to upload proof of your doula training(s) and/or certification(s). Please note, this documentation is required for each type of affiliation you are seeking.

You will also need to upload 2 written references and/or client testimonials. Each must include contact information for the author.

If you do not have these documents on hand, you can save this application (by clicking the white Save button) and return to it when you're ready. You will not be able to submit it until you have uploaded all required information.
Name*

First NameLast Name
Preferred Pronouns
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please tell us a bit about yourself. What first attracted you to working as a Doula?*
Please describe your ideal client.*
Are you certified in Adult & Pediatric CPR & AED? If not, are you willing to complete/renew this certification?*

Yes, I am currently certified.No, but I am willing to complete/renew this certification.
Are you willing to undergo a current background check for Bloom Baby Doulas to keep on file?*

YesNo
Do you have up-to-date professional liability insurance as a Doula? If not, are you willing to purchase/renew a policy?*

Yes, I currently have professional liability insurance.No, but I am willing to purchase/renew a policy.
How did you hear about Bloom Baby Doulas?*
What interests you most about working with our Referral Agency?*

Important:

Doulas seeking affiliation are not required to hold certification. However, they must provide proof of participation in a reputable training or certification program for each service they intend to offer, as well as verifiable experience when applicable.
What type of doula affiliation are you seeking? Check all that apply.*

Birth doulaPostpartum doulaFertility doulaAbortion/loss/bereavement doula

Fertility Doula Verification
Please share the date of your Fertility Doula training and the name of your trainer/training organization.
If you currently hold a Fertility Doula Certification, please share the name of the certifying organization and any expiration/renewal date that may be applicable.
How long have you been offering Fertility Doula services?
How many families have you supported as a Fertility Doula?
Are you willing and able to provide verification of your Fertility Doula experience based upon your existing client records?

YesNo
Are there any limitations/exclusions you have in providing services as a Fertility Doula (ie: no large pets, no smokers, only serving particular locations, etc.)?
What is your current rate for Fertility Doula services?

Abortion/Loss/Bereavement Doula Verification
Please select the type of services you provide by checking all that apply.

Abortion SupportPregnancy Loss / Stillbirth SupportInfant Loss Support
Please share the date of your training and the name of your trainer/training organization.
If you currently hold a Certification for this role, please share the name of the certifying organization and any expiration/renewal date that may be applicable.
How long have you been offering these specific services?
How many families have you supported, specifically in this capacity?
Are you willing and able to provide verification of your experience based upon your existing client records?

YesNo
Are there any limitations/exclusions you have in providing these services (ie: no large pets, no smokers, only serving particular locations, etc.)?
What is your current rate for these services?

Please complete the following section so that we can more thoroughly understand your current professional offerings.
Do you practice under a registered or assumed business name? If so, please share the name.*
Do you have you a website and/or social media account(s) established for your practice? If so, please list them here.*
Are you currently an in-network or pre-approved doula with any insurance or benefit programs such as Medicaid, Tricare, Carrot, Maven, etc. If so, please share the details (ie: which insurance or benefit program(s) and for which service(s)).*
Do you offer any additional services (ie: Childbirth Education, Lactation Support, Yoga, Bodywork, etc.) within your practice? If so, please share more.*
Do you hold any clinical licensure and or terminal credentials (ie: DPT, IBLC, RN, LCSW, etc.) that enhance your role as a Doula? If so, please share more.*
Do you have any other special skills or experience (ie: languages spoken, related professional training and/or experience, etc.) that you would like us to know about?*
In addition to your work as a Doula, do you hold any other positions at this time? If so, please share the nature of this work and how it impacts your availability as a Doula, if at all.*

Is there anything else that you would like us to know at this time?
Please upload proof of your doula training(s) and/or certification(s) here. Please note, this documentation is required for each type of affiliation you are seeking.*

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Please upload 2 written references and/or client testimonials. Each must include contact information for the author.*

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I declare that the information provided in this application is accurate, complete, and true to the best of my knowledge and belief. I understand that providing false or misleading information may lead to disqualification from the application process or, if discovered after acceptance, termination of any resulting agreement or position, as well as other potential legal consequences. By signing below and submitting this form, I affirm that the information I have provided is my own and has not been altered or falsified in any way.*

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Doula Affiliation Application

Thank you for confirming! Please help us learn more about you and the services you provide.

Birth Doula Verification

Postpartum Doula Verification

Fertility Doula Verification

Abortion/Loss/Bereavement Doula Verification

Please complete the following section so that we can more thoroughly understand your current professional offerings.