Subsidized Labor Doula Services Application
Fill out this form to apply for subsidized doula services provided by members of the Utah Doula Association.  PLEASE NOTE we will NOT be able to match you with a specific doula.
Name *
First and last name
Your Date of Birth *
Baby's Estimated Due Date. (Please allow at least 8 weeks before your due date) *
Phone number *
What city do you live in? *
Where do you plan to  deliver? *
Who is your doctor/midwife? *
Do you currently have a doula? *
Type of Services-Currently most services may be virtual based on hospital policy. If your hospital/place of birth limits doula support to virtual only are you still interested in receiving support? *
Do you have an FSA or HSA? *
Why are you applying for discounted services? The more details you provide, the better we can evaluate your application. *
What number of pregnancy is this? *
If you have had a previous pregnancy, what was the outcome of the pregnancy/birth? *
What amount could you contribute toward doula services?  This could either be a financial contribution or trade.  If you have something to trade, please indicate a monetary value along with the offering. *
Have you taken a childbirth education class this pregnancy? If so, what class and where? *
Any other considerations we should take into account *
How did you hear about this program? *
Are you willing to write a review after the birth? *
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