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