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 info@harambeevillage.org
Client's Name *
Your answer
Client's Phone Number *
Your answer
Client's Email *
Your answer
The best way to contact your client is by: *
City *
Your answer
Reason for Referral: *
Required
Estimated Due Date or Date baby was born *
MM
/
DD
/
YYYY
Client will be giving birth at:
Does your client know you are making this referral? *
Which of the following apply to your client? *
Required
Which HMO is your client receiving medical care through? *
Required
Is there anything else we should know about your client?
Your answer
Name of person submitting referral *
Your answer
Name Agency/Organization (If applicable)
Your answer
Phone number of person submitting referral *
Your answer
Email address of person submitting referral
Your answer
Submit
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