ANBC Support 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. We offer free services to Indigenous birthing people in Alaska, by their direct request, as an additional support person during pregnancy, labor, postpartum, and/or during other reproductive health events.

We welcome 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 or no 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).

We also offer support for other reproductive health experiences. Please email nativebirthworker@gmail.com with your specific support request if this form does not apply to you.

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!

If you are in need of immediate care for birth support, please call our on call number 907-744-2777 to get connected with a birthworker today.

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

Email *

Please select the type of support you are requesting (check all boxes that apply): *

Prenatal support

Birth support

Postpartum support

Other:

Required

It is best if the birthing person can complete the electronic form themselves. However, if that is not possible, this form can be completed by someone making the referral on their behalf, with their consent. If you are making a referral, please fill out the form using the information of the person seeking services:
*

I am completing this form for myself.

I am completing this form for someone else - please list your name and email below in "Other:"

Other:

Required

Full name: *

Do you identify as Native or Indigenous? *

yes

Please list your cultural / tribal affiliation: *

Estimated due date (write NA if not pregnant): *

If requesting postpartum support, when did you give birth?

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 (select all that apply):

E-mail

Phone call

Text

Other:

Where do you plan to give birth? (write NA if not pregnant) *

Number of previous births: *

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 from ANBC: *

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 responsibility to communicate my needs and to 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 I give birth.

I understand that my unidentifiable basic information may be included in ANBC program evaluation for advocacy purposes. Types of basic information grouped together from all request forms received may include cultural group, home community, and place giving birth. We do not share names, contact information, or personal details with anyone other than your ANBC care team.

I understand that the best way to stay informed of ANBC events and services is by subscribing to the monthly e-newsletter. I have subscribed to the newsletter and agree to receive this form of communication from ANBC. Subscribe here: https://mailchi.mp/4d3443e4bc14/anbc_emailnews

Required

The Alaska Native Birthworkers Community also provides other services to birthing families. Please share your ideas for events, community activities or other supportive services we could consider offering:

We invite you to subscribe to our monthly e-newsletter and share this link with your network to stay informed about other services we offer, such as birthworker trainings, cultural sharing circles, childbirth preparation retreats, drop in visiting circles and more!

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

If you are in need of immediate care for birth support, please call our on call number 907-744-2777 to get connected with a birthworker today.

A copy of your responses will be emailed to the address you provided.

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