CVD Postpartum Doula Services Referral Form
CVD is a birth justice organization providing comprehensive doula support with a focus on vulnerable communities in the Chicago-land area. Doulas provide educational, physical and emotional support before, during and immediately after labor and childbirth. A doula does not provide any type of medical care.

Thank you for completing this form to obtain a postpartum doula. This service is designed to give around 20 hours of postpartum support (maybe more if agreed upon by family and doula) within 12 weeks postpartum. We do ask for a donation of $100. If you have any questions about the program please email postpartum@chicagovolunteerdoulas.org
Full Name of person wanting service *
Please give first and last name
Your answer
Pregnancy status? *
Partner/Spouse's Name
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Phone Number *
xxx-xxx-xxxx format
Your answer
Phone Number 2
Your answer
Email address (double check for accuracy) *
this will be the first line of contact. (please check your spam if you are awaiting contact)
Your answer
Race, ethnicity or nationality? *
Primary Language
If you prefer a doula who speaks your native language please note it here
Your answer
Listed below are the roles and responsibilities of the doula as well as the postpartum client. Please read over and enter today's date to agree. Your doula will have a paper copy of this for you *
Postpartum doula will: Come into your home and provide support based on what was agreed --- Be on time--Work in a professional manner at all times ---Have necessary resources/documents—Provide information/education for postpartum recovery, infant/feeding, baby care and safe sleep--NOT make any medical judgment or give advice requiring the expertise of trained medical personnel--NOT administer any medication---Not take over care---NOT be able to drive clients anywhere--NOT be able to provide case management services--Share community resource information--Be clean and practice good hygiene--Provide service only in the families primary residence--Possibly ask to see your discharge papers to get an understanding of postpartum instructions from your care provider Postpartum client will: Agree to let the doula in the home for a minimum of 20 hrs. Days, time in/time out, will be determined by doula and family together--Agree to take a survey once at the beginning of care and once at the end of care to measure the outcomes of this service--Agree to have the doula come into a safe environment--Pets will be secured unless you a conversation with the doula beforehand--No use of nicotine products or controlled substances while the doula is there--Agree to provide a space for the doula to rest close to the baby if wanting overnight support--Agree to sign off on the doulas time and tasks daily--Agree to notify the Postpartum Program Coordinator if you have concerns about your doula assignment--postpartum@chicagovolunteerdoulas.org--Agree to let the doula know at least 8 hours before they are scheduled to arrive if you decide not to use the doula that day--Agree to let the doula know your preferred method of contact to communicate in a timely and consistent manner--Agree to be in the home the entire time that the doula is there--Understand that the person in the postpartum period is the primary client of doula and is the one receiving the service--Speak to the doula about parking, including restrictions--Be open to rescheduling your visit or having another doula come support you if your scheduled doula is unable to due to illness or attending a birth
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Client age range? *
Pronoun? *
Gender *
Check all that apply
Required
Estimated Due Date or date of baby's birth *
Please list your upcoming due date or the date you delivered
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What # pregnancy or child is this? *
Your answer
I am *
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