Please fill out the following information to request your doula.

This is a HIPAA-Compliant Form.

Your Contact Info

First Name *

Last Name *

Phone *

Is it okay to text? *

Yes

Is it okay to call? *

Yes

I consent to receive SMS Notifications from Gateway Doula Team / Message frequency varies. Message & data rates may apply. You can reply STOP to unsubscribe at any time.

I understand that there will be no out-of-pocket cost to me for the doula services package, and I consent to the release of my information for purposes of program documentation and billing.

Your Date of Birth *

About Your Pregnancy & Birth

Last Menstrual Period *

Estimated Due Date / Baby's Date of Birth *

Birth Location (Select one) *

Birthing Clinic Name (If other is seleted)

Examples: Women's Health Associates, Center for Women's Health, Providence Women's Clinic, etc.

Doula Preferences

Do you have a doula preference? If so, please add name below.

Culturally Specific: Nationality, ethnicity, religion, language, etc.

I would like a doula experienced in supporting and safety resources for people experiencing domestic violence.

Yes

Are you a returning veteran?

Yes

Preferences for care:

physical

informational

emotional support

trauma informed

newborn care

sleep relief

support tasks

I'm seeking a doula for the following support

Please share pregnancy complications you wish to have support on.

Insurance Information

All OR residents insurance covers doula care. We can help check your benefit *

I am an OR resident

I am a WA resident on Medicaid

Other

Insurance Type *

Other Insurance Type

Medicaid or Insurance ID *

Additional Information

How did you hear about Gateway Doula Group?

Message, Questions, Comments