Request for Doula Support + Referral
Please note:

This form is designed to help us refer you to a doula that may be a good match for your family. All of the questions in sections 2 and 3 are optional. You do not need to share any information that is uncomfortable or unimportant to you.

Any information you provide in the form is confidential and will be viewed only by the Open Circle Doula Care Coordination team. We may provide a basic summary (not using your family’s name or contact info) to potential Open Circle Sister Doula/s who we feel might be a good match. Your contact information or identifying information will only be shared with our doulas with your express permission.

If you would prefer to provide this information to us in paper format or over the telephone, please email:, or call (401) 338-5466.

Email address *
Name: *
Your answer
Is there anyone else who will be attending your birth? (friend, partner, family member, etc.)
Your answer
Your answer
Planned Place of Birth
Your answer
Estimated Due Date
Provider Name
Your answer
At what week of pregnancy were your other children born?
What classes are you taking or planning to take (at Open Circle or elsewhere)?
Your answer
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