Lincoln Hospital X Bx (Re)Birth Doula Client Pre-Intake Form
Thank you for considering Bx (Re)Birth as a source of support for you and your family during this time in your life.
We are pleased to be working in partnership with Lincoln Hospital to support their patients in achieving respectful and dignified birthing experiences.
The purpose of this form is to provide us with information that will help us connect you with a doula. Once you submit this form you will be contacted by a Bx (Re)Birth team member to discuss some or all of your responses and payment options.
Your responses will also be shared with our team of doulas whose bios and contact information will be shared with you. You will then be asked to contact at least two doulas whose descriptions resonate with you, set up a time to meet with them by phone, and make a decision on who you'd like as your doula from that point.
* Required
Email address
*
Your email
What is your first name?
Your answer
What is your last name?
Your answer
What are your pronouns?
She/her
He/him
They/them
Other
What is your phone number?
Your answer
What is the best way to get in contact with you?
Text Message
Voice Call
Email
Clear selection
What is your address?
*
Your answer
Do you identify as Black, Indigenous or a Person of Color?
Black
Indigenous
Person of Color
Other:
Have you given birth yet?
Yes
No
Clear selection
How many weeks pregnant are you?
Your answer
When is your Estimated Due Date?
*
MM
/
DD
/
YYYY
What number pregnancy is this for you?
1
2
3
4
5
6
Other:
Clear selection
Where are you planning to give birth?
*
Hospital
At home
Birthing Center
Other:
If you are planning to deliver in a hospital, which hospital?
*
Your answer
What else should we know about your pregnancy?
Your answer
What else should we know about your birth goals?
Your answer
What quality traits would you like your doula to possess?
Your answer
What kind of doula support do you prefer?
In-person
Virtual
Combination of in-person and virtual
I need to learn more about virtual doula support to decide if it is something I would want.
Through limited grant funding and donations from generous individuals we are able to waive the cost of doula services ($1000) for community members planning to give birth at Lincoln Hospital. We also welcome any personal financial contribution you wish to make to your doula care, which will go toward collective sustainability. Please indicate this below.
*
I can pay $250.
I can pay $500.
I cannot contribute any money toward doula services.
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