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.
What is your first name?
What is your last name?
What are your pronouns?
What is your phone number?
What is the best way to get in contact with you?
What is your address?
Do you identify as Black, Indigenous or a Person of Color?
Person of Color
Have you given birth yet?
How many weeks pregnant are you?
When is your Estimated Due Date?
What number pregnancy is this for you?
Where are you planning to give birth?
If you are planning to deliver in a hospital, which hospital?
What else should we know about your pregnancy?
What else should we know about your birth goals?
What quality traits would you like your doula to possess?
What kind of doula support do you prefer?
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.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service