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.
* Required
Email address
*
Your email
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:
*
Lacking a birth support person
Under 25
Newly arrived migrant
Refugee background or seeking asylum
Having history of mental health issues
At risk of perinatal mental health issues
Experiencing homelessness or housing issues
A survivor of trauma
Having issues with current or historical substance misuse
Rape victim
Torture victim
Trafficked woman
Survivor of domestic violence
Other
Required
If you ticked other, please explain:
Your answer
Referrer's name:
*
Your answer
Referrer's phone number:
*
Your answer
Mother's name:
*
Your answer
Address
*
Your answer
Phone number
*
Your answer
Email address
Your answer
Estimated Due date
*
MM
/
DD
/
YYYY
Booking Hospital
*
Your answer
Is the mother booked at labour ward or birth center?
*
Labour Ward
Birth Center
Home Birth
Not known
Support the mother needs:
*
Birth support (2-3 meetings berfore birth, birth, 2 visits after the birth)
Post natal support (if woman has no other support, up to 6 weeks after birth, number of hours to be agreed with the team)
Both
Number of children
*
First baby
Second baby
Third baby
Other
Mothers living conditions (secure accommodation, temporary accommodation, living with friend, etc)
*
Your answer
Does the mother have a birth partner? (partner, ex-partner, family member, friend)
*
Yes
No
Not known
Is there anyone in the mother's life who is known to possibly be aggressive or violent?
*
Yes
No
Not known
If you answered yes, please explain:
Your answer
Does the mother have access to public funds?
*
Access to public funds
No access to public funds
Supported by partner
Working but on low income
Other
Level of English
*
Native speaker
Fluent
Elementary
Basic
Other:
Language spoken
*
Your answer
Other agencies involved in the care for the mother contact details (social worker, Hestia, etc.)
Your answer
Other relevant information about the mother (immigration status, language support needs, disability, etc)
Your answer
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
Your answer
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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