GBI Client Intake & Referral Form

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Please complete and send to: doulasdo@gbiky.org

Date of Intake: *

Client Full Name: *

Date of Birth: *

Estimated Due Date or Birth of Youngest Child:

Race/Ethnicity: *

Preferred Language *

Client Phone Number: *

Client Email Address (“N/A” if they do not have one): *

Would you like to sign up for GBI SMS/email to stay updated about resources, events, and closures

Yes

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Client Address: *

When is your next prenatal/ postpartum appointment?

YYYY

Do you have healthcare established for your infant/ child? *

Yes

Who is your Insurance Provider? ("N/A" if you do not have insurance) *

Do you take any medications regularly? *

Do you have a history of (select all that apply): *

High Blood Pressure/Preeclampsia

Diabetes/Gestational Diabetes

None

Other:

Required

Referring Representative Name: *

Referred by/to (Program/Resource): *

Doula'd Up: Up Shelter for Women and Children

Healthy Start

VOA

WIC

GBI OFFICE

Other:

Required

Important Notes: (Include relevant client history, needs, or concerns to be shared with the referral partner.) *

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This form was created inside of Granny's Girls Birth Initiative.