Harambee Village: Referral for Doula and/or Breastfeeding Services
If you are a care provider or social service provider looking to refer a client for birth doula services, postpartum doula services, or breastfeeding support, please fill out this form. Please be sure that your patient or client has agreed to your referral and is expecting to be contacted by us. One of our doulas will get in touch with your client within 7 business days of receiving your referral. Please note that submitting a referral does not guarantee services.
Please note, if you are requesting an on-call volunteer doula for a client who is currently in labor, please call our on-call doula line at 608-535-9525 and leave a message. We do our best to accommodate these requests. Do not send in an online referral for urgent matters! If you have any questions please send us an email at
Client's Phone Number
The best way to contact your client is by:
Reason for Referral:
Birth Doula Services
Postpartum Doula Services
Sister Friend through the Birthing Project
Estimated Due Date or Date baby was born
Client will be giving birth at:
Unity Point Meriter
SSM St Mary's
At home with a licensed Midwife
Does your client know you are making this referral?
Which of the following apply to your client?
Low Income (200% of Federal Poverty Guidelines or less)
19 years old or younger
Client or partner is on active duty in th emilitary
None of the above
Which HMO is your client receiving medical care through?
Quartz (UW Health)
Group Health Cooperative (GHC)
Dean SSM Health
Other (please explain)
Is there anything else we should know about your client?
Name of person submitting referral
Name Agency/Organization (If applicable)
Phone number of person submitting referral
Email address of person submitting referral
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