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Harambee Village Doula & Lactation Care Inquiry Form
Welcome to the village! This form is provided as a convenience to help facilitate your desire for a Harambee Village Doula, your answers and contact info will be shared only within our organization’s trained doulas who all comply with the highest level of confidentiality regulations (HIPPA). Doulas who are available according to your due date, location, and feel they suit your needs will contact you directly to schedule a consultation at no cost.
 
It is important that you provide the best way to contact you, if your phone number changes after submitting this form, please contact Harambee Village by phone or email (608) 535-9525. You may also contact us via our website at www.harambeevillage.org. Your information will be archived after 3 weeks.

DISCLAIMER:
Our commitment extends to doing our best to pair prospective clients with a Doula, however completing this form is not a guarantee that there will be a doula available for your exact due date and location of your birth. If you are currently in labor or having infant feeding concerns requesting immediate care, please call us at (608)-535-9525, instead of using this form.

Your First & Last Name *
Do you have a preferred name? If so, please tell us.
Please tell us your preferred pronouns.
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Please tell us your preferred language.
Your phone number *
How do you prefer we contact you? * *
Required
Do we have your permission to leave a voicemail at number you provided? *
What county do you live in (Columbia, Dane, Dodge, Green, Iowa, Jefferson, Rock, Sauk, Waukesha, etc)? *
How did you hear about Harambee Village? *
Required
What kind of care are you seeking? *
Required
Estimated Due Date or Baby's Birth Date *
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DD
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Where do you plan to birth/ did you birth? *
Which HMO is your client receiving medical care through? *
Required
Would you prefer a doula who is: *
Required
Please share any other info relevant to your search or that you would like your potential doula to know:
Would you like to receive additional information such as local resources, events, and news from Harambee Village? *
Have you submitted this request form previously? *
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