Ashe X Bx (Re)Birth Doula Client Pre-Intake Form
Thank you for considering Bx (Re)Birth as a source of professional support for you and your family during this time in your life. We are so pleased and grateful that our friends at Ashe Birthing Services trust and respect our work enough to connect YOU to us for doula support!

The purpose of this form is to provide us with information that will help us connect you with a doula. Once you submit this form you will be contacted by a Bx (Re)Birth team member to discuss some or all of your responses and payment options.
A note on payment: We believe that birth work should always remain community-centered and driven. With that philosophy in mind, we strive to support our people in investing in their own health and well-being. Our doula services will always be accessible, affordable, and tailored to individuals' unique needs. The bulk of your payment goes toward paying your doula an equitable fee for their service, and we set a little aside to sustain our collective's efforts.

Lastly, your responses will also be shared with our team of doulas whose bios and contact information will be shared with you. You will then be asked to contact at least two doulas whose descriptions resonate with you, set up a time to meet with them by phone, and make a decision on who you'd like as your doula from that point.
Email address *
What is your first name?
What is your last name?
What are your pronouns?
What is your phone number?
What is the best way to get in contact with you?
Clear selection
What is your address? *
Do you identify as Black, Indigenous or a Person of Color?
Have you given birth yet?
Clear selection
How many weeks pregnant are you?
When is your Estimated Due Date? *
What number pregnancy is this for you?
Clear selection
Where are you planning to give birth? *
If you are planning to deliver in a hospital, which hospital? *
If you are planning to deliver in a birthing center, which birthing center?
Clear selection
What else should we know about your pregnancy?
What else should we know about your birth goals?
What quality traits would you like your doula to possess?
What kind of doula support do you prefer?
We are committed to ensuring that every doula is paid equitably for every client they support, and that the collective receives funding to continue to provide this necessary service to our community affordably. That said, our doula services are $2100 and include 2-3 prenatal visits with your doula, labor support and 2 postpartum visits. Please indicate below which service option you would like. While no requests will be denied for an inability to pay, our ability to do so does depend on availability of funding.* Payment plans are available. *
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy