Discounted Doula Services Application
Fill out this form to find out if you qualify for free or significantly discounted doula services.
Email address *
Name *
First and last name
Your answer
Your Date of birth
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Your estimated due date *
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Phone number *
Your answer
What city do you live in? *
Your answer
Where do you plan to deliver? *
Your answer
Do you have an FSA or HSA? *
Why are you applying for discounted services? *
Your answer
Are you or your partner a veteran of the U.S. military? *
Are you or your partner a member of law enforcement or emergency services? *
What number of pregnancy is this? *
Your answer
If you have had a previous pregnancy, what was the outcome of the pregnancy/birth? *
Your answer
Have you taken a childbirth education class this pregnancy? If so, what class and where? *
Your answer
Any other considerations we should take into account
Your answer
Our regular fee is $1,00. What do you feel like you could contribute to this? *
Your answer
If accepted, do you agree to post reviews in trade for our discounted services? *
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