Erie Niagara AHEC Mother-Doula Program Enrollment Form
This form is to be completed by expectant mothers in Erie county who are willing to participate our 1 year doula and extended services program. You must be a resident of Erie County, receive Medicaid-benefits, and be before 30 weeks gestation. 
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Email *
First Name *
Last Name *
Date of Birth *
Phone Number (xxx) xxx-xxxx *
Home Street Address *
City *
State *
Zip Code *
Ethnicity/Race  Check all that apply. *
Are you a permanent resident of Erie county? *
Are you at 30 weeks or before? *
What is your 1st language? *
What is your 2nd language? *
What trimester of your pregnancy are you currently in? *
When is your due date? *
Do you qualify/receive Medicaid benefits? *
What company do you receive benefits through?  *
Are you willing to participate in this program for a full year after birth? If no, please explain. *
Are you willing to participate in maternal and infant health trainings? If no, please explain in "other" box.  *
Do you have reliable transportation? *
Will you require transportation assistance? *
Do you have a reliable source of communication? (i.e. phone, tablet, laptop, computer, etc.) *
If you have a doula in our network that you would like to request, please indicate here. 
How did you hear about this program? *
A copy of your responses will be emailed to the address you provided.
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