ASL Birthworker Questionnaire

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What is your full name / preferred name? *

What kind of service(s) do you provide? *

Birth Photography

Childbirth Education

Doula (Birth)

Doula (Postpartum)

Lactation Consultation

Midwifery

Placenta Encapsulation

Other:

Required

Where do you provide your services? *

Please share your biography here.

List all certifications, licenses & other recognitions you have. *

If you are a student doula/midwife/other birth worker, what kind of study or assistance do you need to perform in order to get your certification/license?

Are you willing to travel long distances (ie. out of state) for clients? *

Yes

Maybe

I don't know

Only upon agreement

Other:

What is your signing level? *

Novice

Intermediate

Fluent

Native

Other:

List all certifications, licenses & other recognitions you have in accordance with your signing level. *

How should clients contact you? Please include your business & contact information. *

Any additional information or comments you wish to share with your clients?

Thank you for your time!
Please send a photo of yourself to ASLBirth@gmail.com to be placed next to your listing on the website.

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