Letty Owings Center Client Referral

Please fill out the following information to request your doula.

This is a HIPAA-Compliant Form.

Staff Contact Info

Staff Name *

Staff Email *

Staff Phone *

Client Contact Info

First Name *

Last Name *

Email *

Is it okay to email?

Yes

Phone *

Client currently has daytime access to a cell phone?

Yes

Alternate Phone? (If no access to cell phone)

is it okay to text? *

Yes

is it okay to call? *

Yes

Your Date of Birth *

About Your Pregnancy & Birth

Last Menstrual Period:

Birth Location (Name of Hospital or Specific Location)

Estimated Due Date

About Your Postpartum

Baby Name

Baby DOB (NA if still pregnant) *

Sex of the baby

Medical Issues or Special Needs of the Baby

Doula Preferences

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

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

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

Yes

Preferences for care:

physical

informational

emotional support

trauma informed

newborn care

sleep relief

support tasks

I would like a doula with SUD experience.

Yes

I'm seeking a doula for the following support

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

Private Self Pay
OHP Care Oregon
OHP Pacific Source
OHP Trillium
OHP Providence
OHP Kaiser
OHP OHSU
TriCare
OHP - Other
FSA/HSA
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Provider and Provider Group *

Insurance Provider *

Insurance ID

Upload FACE Sheet OR Insurance Card

Upload ROI *

Additional Information

Primary Counselor

Date of admission to Letty Owings Center *

Message, Questions, Comments

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