Roots of Labor Birth Collective/Colectiva Raíces de Parto- Doula Referral Form/ Solicitud para Referencias de Comadrona
Client First Name/ Primer Nombre de Cliente
Your answer
Client phone /número de teléfono *
Your answer
Is this phone number your personal line?/ ¿Es este número de teléfono su línea personal?
Referral Source Name (if you are requesting a doula for yourself, write “self”)/ Fuente de Referencia
Your answer
Age/Edad
Your answer
Email
Your answer
Race and/or Ethnicity/ Raza y/o Etnicidad
Your answer
Primary Language/ Idioma Principal
Your answer
Estimated Due Date/ Fecha Estimada de Parto
MM
/
DD
/
YYYY
Is this your first birth? Es este su primer parto?
Where are you planning to deliver?/ Donde planea tener su parto?
Name of hospital, birth center, or home address for home birth/ Nombre de hospital, centro de nacimiento, o enderezo de su casa si pariendo en casa
Your answer
Do you have any requests regarding who your doula will be?
For example: A doula who speaks my primary language. A doula who has experience working with survivors of sexual abuse. A doula who has experience working with people who have a certain disability. A doula with my own sexual orientation./ Por ejemplo: Una doula quien habla mi idioma principal. Una doula quien tiene experiencia trabajando con sobrevivientes del abuso sexual. Una doula quien tiene experiencia trabajando con gente deshabilitada. Una doula de la misma orientación sexual que la mía.
Your answer
What is your perceived economic status? Cuál es su estatus económico?
Are you able to comfortably meet your needs for daily living? Puede cómodamente satisfacer sus necesidades diárias?
Our asking price is $2000. We do offer a sliding scale from $1000-$2000. Would you comfortably be able to contribute to the compensation of your doula? / El costo promedio para una doula es $2000. Ofrecemos un rango entre $1000-$2000. Podría usted compensar a su doula cómodamente?
Note: We do not turn clients away based on inability to pay. Scholarships may be available. In addition, if you have MediCal coverage, you may be able to receive reimbursement. // No rechazamos clientes basado en la habilidad de pagar. Becas pueden estar disponibles.
I am able to contribute the following: $____0.00_________ / Puedo contribuir lo siguiente: $____0.00_________
Your answer
Is there anything else you would like us to know?/ Hay algo más que quisiera que sepamos?
Your answer
Consent *
Required
*
By checking this box I authorize Roots of Labor Birth Collective to use email to share the protected health information that I have inputted here with the Doula coordinator and/or my assigned Doula.  I acknowledge that RLBC has advised me that their current email system does not provide the technological security to protect my personal information.  In choosing to communicate with the Doula coordinator and/or my Doula in this way I will not hold RLBC and/or its affiliates responsible for any unintended parties obtaining this information as a result of such risk // En firmar aquí autorizo el uso de correo electrónico por el Roots of Labor Birth Collective para compartir información protegida sobre la salud cual yo he compartido aquí con la coordinadora de Doula y/o mi Doula designada. Reconozco que el RLBC me ha avisado que su sistema corriente de correos electrónico no provee seguridad tecnológica para proteger mi información personal. En elegir comunicarme con la coordinadora de Doulas y/o mi Doula en tal manera, no considerare al RLBC y sus afiliados responsables si grupos con cual no se le intente compartir información obtiene esta información como resultado de este riesgo..
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