Discounted Doula Services Application

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Fill out this form to find out if you qualify for free or significantly discounted doula services.

Email *

Name *

First and last name

Your Date of birth

YYYY

Ethnicity *

Hispanic or Latino or Spanish Origin

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or other Pacific Islander

White

Your estimated due date *

YYYY

Phone number *

What city do you live in? *

Where do you plan to deliver? *

Do you have an FSA or HSA? *

Yes

Why are you applying for discounted services? *

Are you or your partner a veteran of the U.S. military? *

Yes

Are you or your partner a member of law enforcement or emergency services? *

Yes

What number of pregnancy is this? *

If you have had a previous pregnancy, what was the outcome of the pregnancy/birth? *

Have you taken a childbirth education class this pregnancy? If so, what class and where? *

Any other considerations we should take into account

Our regular fee is $1,000. What do you feel like you could contribute to this? *

If accepted, do you agree to post reviews in trade for our discounted services? *

Yes

Submit

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