The Doula Project Resource
Client Qualification Questionnaire
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Email *
Would you prefer in-person or virtual visits?  *
Which doula are you requesting? Please include the name and location.  *
Name (First, Last) *
Phone Number *
Email *
What is your physical address? *
What is your Date Of Birth? *
MM
/
DD
/
YYYY
What is your Expected Due Date? *
MM
/
DD
/
YYYY
Is this your first pregnancy? *
Are you currently pregnant and have a history of preterm delivery? *
Are you currently pregnant and previously experienced a loss? (Miscarriage, still birth, early infant death) *
Where are you planning to give birth? *
Do you want doula support for this pregnancy? (Virtually/In person) *
 Are you currently employed? *
If yes, Does your employer offer insurance? *
Are you currently receiving Medicaid in your state? *
Insurance Provider(i.e. Humana, United Health, Sunshine) (please include card number etc) *
What is your families’ Net monthly income? Please refer back to Poverty Guidelines *
Doula Project Resource Income Guildeline
A copy of your responses will be emailed to the address you provided.
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