Doula Request Form
Please take a moment to complete this form. Your responses will help us to find a doula for you based on your location, estimated delivery date, and any other information you provide. Your answers will remain confidential, and only key information (such as contact information) will be shared with your doula if we are able match you.
We have a small pool of dedicated volunteer doulas, and unfortunately we receive more requests than we are able to match. Please note that completing this form does not guarantee that we can find a doula for you, although we will try our best and communicate with you along the way.
Please also know that we typically work 2-3 months ahead, so if your estimated delivery date if further in the future, we may not be able to prioritize finding you a doula just yet. But, completing this form as early as possible is still helpful!
How did you hear about us?
Estimated delivery date
Alternative Birth Care Unit (ABC) at Providence Hospital, Southfield (Oakland County)
Beaumont Hospital, Dearborn (Wayne County)
Beaumont Hospital, Farmington Hills (Oakland County)
Beaumont Hospital, Grosse Pointe (Wayne County)
Beaumont Hospital, Royal Oak (Oakland County)
Karmanos Birth Center, Beaumont, Royal Oak (Oakland County)
Beaumont Hospital, Troy (Oakland County)
Beaumont Hospital, Wayne (Wayne County)
Henry Ford Macomb Hospital (Macomb County)
Henry Ford West Bloomfield Hospital (Oakland County)
Hutzel Women's Hospital (Wayne County)
Providence Hospital & Medical Center, Southfield (Oakland County)
Providence Medical Center - Providence Park (Oakland County)
Sinai-Grace Hospital (Wayne)
St. John Hospital & Medical Center (Wayne County)
St. Joseph Mercy Ann Arbor (Washtenaw County)
Von Voigtlander Women's Hospital, University of Michigan (Washtenaw County)
Homebirth (please specify county below)
OTHER (see below)
Delivering at (OTHER)- please include County
On Call Doctor/Midwife
Client Demographic and Contact Information
County of residence
Your age (at time of delivery)
Annual Combined Household Income
Self Defined Race/Ethnicity
African American Non Hispanic
White Non Hispanic
Prefer Not To Answer
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