Community Doula Service
Name *
Full Address *
Email *
Phone number *
DOB *
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DD
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Do you identify as a Black woman? *
If you do not identify as a Black woman; please list any risk factors that would make you eligible for this program. *
If you do not identify as a Black woman, are you prepared to accept the service fee of 1% of your income? (Payment plans are allowed) *
Do you have transportation? *
How did you hear about this program? *
This short application does not guarantee your acceptance to receive service. You will be required to book a (free) 30-minute consultation at our office, where you will provide any necessary documents, payments, etc. You will be notified by email and phone to let you know what documents may be needed, and to schedule your consultation. Do you understand? *
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