Alliance of Black Doulas for Black Mamas - Patient Form
Please complete this form if you are a Black pregnant woman requesting a Black labor support Doula.  You will be participating in Alliance of Black Doulas for Black Mamas grant program.
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Full Name *
Do you identify as Black *
What is your Estimate Date of Delivery *
As of today how many weeks are you? *
Address *
City, & County *
Cell Phone Number. *
Additional phone number(s) you can be reached at.
Partner/Support person. Please provide their name and a phone number they can be reached at.
How did you learn about this program? *
Where do you receive your prenatal care? *
If Private OB/GYN or Other please give practice name *
Where are you planning to deliver your baby? *
Do you have any children? *
If yes, how many children do you have and what are their ages?
Have you had a vaginal birth in the past? *
Have you had a cesarean birth in the past? *
If you had a prior cesarean birth, do you want to try for a vaginal birth this time?
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Have you had a good birthing experience previously?
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What do you think makes a good birthing experience? *
If no, please explain.
If you could change anything about your past birthing experience(s), what would you change?
Have you heard of a Doula before now? *
What do you think a Doula does? *
Have you had a Doula for a pregnancy previously?
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If yes, was it a private self paid or a volunteer Doula?
Did you ever consider having a private doula? *
If not why not?
What do you believe is the cost of a private doula? *
If all things are going well, would you like to labor at home *
By submitting this application you are requesting a labor support Doula from the grant program Alliance of Black Doulas for Black Mamas.  This service is valued at $850 but will be at no cost to you.  You are agreeing to an initial phone conversation with the Doula (approx. 15 minutes), one in-person visit (1-2 hours), labor support for active labor and one postpartum visit (approx. 1 hour).  The Doula will also offer to accompany you to one prenatal appointment.  During your first in person visit with the Doula you will be required to sign a HIPPA release form and a photo release form.  In exchange for your participation in the Doula grant program you are agreeing to complete a survey for the Doula's certification, an online survey for the grant project, as well as a phone interview.  As a thank you for participating in our program, you will be offered a pregnancy photo shoot. *
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