Birthing Circle Doula Project Application
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Email *
Name: *
Birth Partner's Name: *
Estimated Due Date: *
Baby's sex (if known) *
Planned Place of Birth: *
Home Address: *
Phone: *
Other Children & Ages: *
Provider: *
Others you plan to have present at the birth: *
Pediatrician: *
What kind of support are you looking for from the Frederick Doula Project? *
Reason you would like support: *
How did you hear about us? *
Do you meet the financial requirements for WIC eligibility? *
Any difficulties during pregnancies and/or births in the past? (gestational diabetes, hypertension, preeclampsia, premature birth, breech, cesarean) *
Any other health concerns that aren't pregnancy related? *
Do you or have you ever experienced mental health challenges? *
Have you ever taken a childbirth education class? *
Is there anything you would like us to know about your needs? *
Any race, cultural, religions birth or tradition requests? *
Are there any other specific resources you would like us to provide? (IE, breastfeeding support, formula support, mental health, etc). *
Any further comments?
Date of Application: *
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