Birth Support Person Request Form

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The mission of the Alaska Native Birthworkers Community is to serve Native birthing families to feel supported, well cared for, and full of the information they need to make confident choices around reproductive health, birthing, and parenthood. As part of this, we offer a volunteer service to birthing parents to be present during birth as a labor and birth companion for additional support.

We welcome birth support requests from our community, and we will use the following criteria to prioritize support:

The birthing person identifies as Native or Indigenous AND one or more of the following applies:

- The birthing person is leaving their home community in rural Alaska to give birth, OR

- The birthing person has limited orno local support, OR

- The birthing person is seeking cultural connections, OR

- The birthing person will be giving birth for the first time OR

- The birthing person has any health risk factor (for example a high-risk medical condition, history of trauma, mental health disorder, high-risk social situation).

If you are unsure about your eligibility for our services, please complete the form or e-mail us and we will follow up with you. We are also happy to help make referrals to other doula services.

Completing this form does not guarantee that we will be able to match you with a birthworker, but we will try our best!

For more information please visit www.nativebirthworkers.org or www.facebook.com/nativebirthworkers. You can email nativebirthworker@gmail.com with any questions.

Email *

Full name: *

Do you identify as Native or Indigenous? *

yes

Other:

Please list your cultural / tribal affiliation: *

Estimated due date: *

What do you like to be called?

Pronouns (i.e. she/they/he etc.):

Age: *

Phone number: *

Mailing address (street address / PO box): *

City, state, zip:
*

If your home community / ancestral homeland is different from where you currently live, please list your home community here:

Best method for communication:

E-mail

Phone call

Text

Video call (i.e. Zoom, FaceTime)

Other:

Where do you plan to give birth? *

Please briefly share about what support system you currently have, who else will attend your birth (if applicable), and what additional support you are looking for during and possibly after birth: *

Please share any other information you would like us to know about regarding your identity, family, reproductive history, current pregnancy, birth plan, postpartum care plan, etc.

Who is your emergency contact (name, pronouns, relationship, phone number, email address)?

How did you hear about us? *

friend / family / community member

my nurse / provider

ANBC website

social media

flyer / brochure

word of mouth

other ANBC events

community presentation

Other:

Required

Please read and agree to the following: *

I understand that the Alaska Native Birthworkers Community is a community led effort to support families and is not affiliated with any other institution. I understand they will only have access to the information I share with them, and that it is my responsiblity to communicate my needs and invite a support person into my birthing space.

I understand that the role of an ANBC birth companion is to offer emotional, physical and informational support during pregnancy, birth and postpartum, and that medical care decisions should be discussed with my midwife, doctor or provider team.

I understand that filling out this form does not guarantee I will be matched with birth support on the day my baby is born.

I understand that during an initial intake with a birthworker following the submission of this form, I will be asked about my COVID-19 safety practices, needs, preferences and vaccination status and that I can ask about the birthworker care team’s vaccination, testing, or precautionary measures.

I understand that my unidentifiable information will be used for program services and not be shared with anyone other than ANBC birthworker(s).

Required

The Alaska Native Birthworkers Community also provides other services to birthing families. Please indicate your interest in any of our other services below:

I would like to participate in virtual talking circles to connect with other Native birthing families and birthworkers.

I would like to connect with a Native birthworker to gain additional support during my pregnancy.

I am interested in participating in a childbirth preparation class.

I am interested in receiving training to become an Indigenous birthworker.

Other:

We invite you to subscribe to our newsletter to stay informed about other services we offer, such as birthworker trainings, cultural sharing circles, childbirth preparation retreats, virtual talking circles and more!

Subscribe here: https://mailchi.mp/4d3443e4bc14/anbc_emailnews

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