CoCo Doulas Interest Form

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Hello! Welcome to the CoCo Doulas Program at FIERCE Advocates.
The CoCo Doulas are Black trained birth workers ready to meet and serve you exactly where you are in your life right now. They are here to guide and support you through your pregnancy and into parenthood.
Please tell us more about yourself by answering the following questions below.
You will be contacted by Oni, the program assistant to complete your intake form.

Please be aware that completing this form, does not assume program eligibility or enrollment.

Due to high interest in our county, we will contact you based on your due date if we have the capacity to serve you at the given time.

Email *

We now begin doula services with families starting at 23 weeks of gestation. Once you are between 23-30 weeks, you will be contacted by the program assistant or your assigned doula. Currently, how many weeks are you? *

First Name *

Last name *

Your Date of Birth: *

YYYY

Age *

City or Town: *

Postal code or ZIP code: *

Best Phone Number to contact you: *

Partner/Best Emergency Contact Number:

Are you a Contra Costa Resident? *

Yes

I am relocating here

Required

Address *

What is your country of origin? *

Do you identify as Black or African-American? *

Yes

Baby's due date: *

YYYY

How do you prefer to receive your doula services? ( Select all that apply) *

In person ( at my home, in a park etc)

Over the phone

Virtually via Zoom/Facetime

Required

Where did you find out about our program? *

Black Infant Health

WIC

African American Baby Shower

My Doctor/ Provider

My Social worker

At a local fair event

Word of mouth from a friend

Another Organization

Required

Thank you! Babies are being born everyday. You will have a beautiful birth, and beautiful baby. Let's doula it!

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