Cornerstone Doula Screening Form
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Email *
Name (First, Last) *
Street Address *
City, State, Zip Code *
Phone Number *
Date of Birth *
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Are you a current client of Cornerstone? *
Estimated Delivery Date *
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First date of last menstrual period *
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Is your pregnancy high risk? *
Is this your first child? *
What is your reason for wanting a doula? *
Important Note*
Our doula services at Cornerstone Pregnancy Services are intended to encourage prenatal and postpartum education to promote positive birth outcomes. The doula professional will not take the place of your medical provider and is not intended to treat or provide diagnostic prenatal care. It is required that you are seen by a licensed medical provider while enrolled in the Doula Program provided by Cornerstone Pregnancy Services.
Are you able to commit to educational classes at Cornerstone as determined by your doula? *
Are you willing to maintain monthly contact with your doula throughout your pregnancy, during labor, delivery, and postpartum period?   *
Do you currently receive (check all that apply): *
Required
Please type your name below to confirm your signature. *
Today's date. *
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By giving us your contact information and signature, you are indicating that it is okay for us to call, email, or text.

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