Neighbourhood Doulas Support Application Form
The information contained in this communication is confidential. It is intended solely for the individual or entity to whom it is addressed and others authorised to receive it.
Email address *
We provide free services for women who don't have a suitable birth partner and who are experiencing financial hardship* and at least one of the following:
* PLEASE NOTE: We reserve our right to retract our free support services if we perceive that the mother is not in financial hardship and could afford a doula privately.
The mother is: *
Required
If you ticked other, please explain:
Referrer's name: *
Referrer's phone number: *
Mother's name: *
Address *
Phone number *
Email address
Estimated Due date *
MM
/
DD
/
YYYY
Booking Hospital *
Is the mother booked at labour ward or birth center? *
Support the mother needs: *
Number of children *
Mothers living conditions (secure accommodation, temporary accommodation, living with friend, etc) *
Does the mother have a birth partner? (partner, ex-partner, family member, friend) *
Is there anyone in the mother's life who is known to possibly be aggressive or violent? *
If you answered yes, please explain:
Does the mother have access to public funds? *
Level of English *
Language spoken *
Other agencies involved in the care for the mother contact details (social worker, Hestia, etc.)
Other relevant information about the mother (immigration status, language support needs, disability, etc)
We would like to create a safe environment for our mothers and also our supporting Doulas.Please mention any medical information (e.g.infectious disease) that could potentially put our Doulas at risk
Confidentiality
This form contains confidential and proprietary material for the sole use of the intended recipients. We adhere to GDPR guidelines and will only keep the submitted information whilst we are working with the mother. We will not share this information with any other agencies.
Thank you for your referral. We will contact the mother as soon as we find a Doula for her.
A copy of your responses will be emailed to the address you provided.
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