Gennisi Charitable Birth Services, Inc Intake Form

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Name *

Full Address *

DOB *

YYYY

Email *

Phone Number *

How did you hear of Gennisi Charitable Birth Services, Inc.? *

What is your estimated due date? *

YYYY

Are you seeking birth support, postpartum support, or both? *

Birth

Postpartum

Both

Do you identify as African American?

**Your answer will not be discriminated against regardless of race, ethnicity, or socioeconomic status

Yes

If you do not identify as African American, please list any risk factors that would make you eligible for this program.

Are you prepared to accept any potential fees based on your eligibility and based on our available funding? *

Yes

This service is for low-income and those who receive assistance such as WIC, TennCare, or live in some sort of public housing. Do you fit this criteria? If not, please visit www.miraclevbc.com for other doula service options. *

Yes

Are you giving birth in Knoxville, TN? *

Yes

If you are not giving birth in Knoxville, TN, where are you giving birth? *

This short form application does not guarantee acceptance to receive service. You will be required to schedule a 30-minute consultation where you will provide any necessary documents, payments, etc. You will be notified by email and phone to let you know what documents may be needed, and to schedule your consultation. Do you agree? *

Yes

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