Postpartum Doula Client Interest Form
We are excited that you are reaching out to us for doula support. If you have additional questions about the role of a postpartum doula please check out this article http://americanpregnancy.org/planning/post-partum-doula/ as well as http://www.dona.org/mothers/faqs_postpartum.php

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 low-cost or 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. Please feel free to call or email joyinbirthingfoundation@gmail.com if you have any additional comments, questions, or concerns.Thanks again!

First Name *
Your answer
Last Name *
Your answer
Your Date of Birth *
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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.
Partner's Name (if applicable)
Your answer
Phone Number *
Your answer
Email
An automatic email will be sent to confirm your submission once you have completed this form.
Your answer
Address *
Your answer
Date or Expected Date of Baby's Birth *
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DD
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YYYY
Baby's Sex and Name
Your answer
Are you breastfeeding or expect to breastfeed? *
What type of insurance do you have? *
ex: Medi-Cal, no insurance, private insurance company
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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