Community-Based Doula Program Interest
Thank you for your interest in the HealthConnect One Community-Based Doula Program Model.

Please complete this interest form and someone on our staff will respond within 10 business days.

Email address *
Name *
Your answer
Job Title/Position (if applicable)
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Phone Number *
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Name of Organization (if applicable)
Your answer
Age of Organization (if applicable)
Your answer
Website
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Street Address *
Your answer
City *
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State *
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Zip Code *
Your answer
Background
If you can, please let us know a little more about you, your community, and what interests you about the Community-Based Doula Program. It is not necessary to answer all of these questions, but anything you can share will help to form the basis for our conversation.
What interests you about the Community-Based Doula Program? What problem(s) are you trying to solve, or what challenge(s) are you aiming to overcome?
Your answer
What communities or populations are you working with?
Your answer
Do you currently provide services for pregnancy, birth, breastfeeding, and/or early parenting? If so, what kinds of services do you provide?
Your answer
What work has your organization engaged in and/or done internally regarding racial equity? How might a Community-Based Doula Program improve racial equity and health equity in your community?
Your answer
Thank you for your interest!
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