Birth Doula Client Interest Form
We are excited that you are reaching out to us for doula support. This questionnaire helps us to match you with doulas that are the best fit for you. Our services are provided on a sliding scale basis based on your yearly income for the current year. If you qualify for pro-bono services, our doulas are volunteering their time to support you through your pregnancy, birth and postpartum and so we do encourage our clients to gift their doula whatever they can to help compensate for her expenses.

The Joy in Birthing Foundation does not discriminate on the basis of race, creed, color, ethnicity, national origin, religion, sex, sexual orientation, gender expression, age, height, weight, physical or mental ability, veteran status, military obligations, and marital status. Please note that it may take up to 3 weeks to find the perfect match due to the amount of requests that we are getting at this time and placement with one of our volunteer doulas is NOT guaranteed.

First Name *
Your answer
Last Name *
Your answer
Your Date of Birth *
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Partner's Name (if applicable)
Your answer
Phone Number *
Your answer
Alternate Phone Number if applicable (please include whose number it is)
Your answer
Email
An automatic email will be sent to confirm your submission once you have completed this form.
Your answer
Address
Your answer
Estimated Due Date *
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Optional: Please select the race or ethnicity that you most identify as:
Joy in Birthing Foundation is gathering information on demographics of our clientele for research purposes. Your answer or omission of this question will in no way impact your ability to work with Joy in Birthing Foundation doulas.
Hospital/Expected Place of Delivery *
Your answer
Baby's Sex and Name (if applicable)
Your answer
Are you receiving any additional support services?
How much is your annual household income? *
"Income" is total amount expected to be made by household in the current year. "People in household" is defined by yourself+legal partner+dependent children.
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