Client Name *

First Name

Last Name

Client Phone Number *

(###)

###

####

When is the estimated due date? *

Doula requests are ONLY accepted between 28 weeks of pregnancy to 6 weeks postpartum

MM

DD

YYYY

If a Doula is not available to provide postpartum services, would you be interested in any of the following?

Postpartum Adjustment Planning

Virtual Postpartum Check-ins

Community Meal Train

If you are requesting subsidized doula support, please confirm that you are either under the age of 24 or can provide income/tax statements that confirm your annual household income is below $40,000.

Yes

No

Which of the following do you identify with? (Check all that apply) *

Our services are reserved for individuals and families who are Indigenous, Black, or people of colour.

Indigenous or First Nations

Black or person of African descent

South Asian

Middle Eastern or Arab

Latin American

Pacific Islander

White (only if partner and/or child are BIPOC)

Mixed-race

Other

Which of the following do you identify with? Please disclose what you feel comfortable with.

This information helps us match you with a doula who may be the best fit and/or have shared lived experiences.

Newcomer or Refugee

No MSP or Undocumented

2SLGBTQ+

Youth

A person with a disability

A person with a substance use disorder

Single or Solo Parent

A person requiring english translation

A person with previous birth trauma

A person who has experienced pregnancy loss before

Would you like to receive monthly e-newsletters from us with updates and upcoming programs/offerings?

Yes

Would you like to be contacted about paying-it-forward by contributing to our Doula Access Fund for low-income families?

Yes