Doula Services Intake Form Welcome to the ICO4MCH Doula Program!We are delighted that you are interested in receiving doula support throughout your pregnancy, birth, and postpartum journey. Please complete this brief form to help us better understand your needs and connect you with the doula best suited to support you during your upcoming birth. All responses are confidential and will be used solely for program purposes. Contact Information Question Title * 1. Full Name Question Title * 2. Date of Birth Question Title * 3. Email Address Question Title * 4. Phone Number Question Title * 5. County of Residence Hoke County Montgomery County Richmond County Scotland County Other (please specify) Question Title * 6. Race- Check all that apply American Indian or Alaska Native Asian or Asian American Black or African American Native Hawaiian or other Pacific Islander White or Caucasian Prefer not to say Question Title * 7. Ethnicity Hispanic or Latino Non-Hispanic or Latino Prefer not to say Pregnancy Information Question Title * 8. Estimated Due Date Due Date Date Question Title * 9. Is this your first pregnancy? Yes No Question Title * 10. Where do you plan to give birth? Hospital Birth center Home Not sure yet Question Title * 11. Name of hospital or birth center (if known) Question Title * 12. Do you currently have a healthcare provider, OB, or midwife? Yes No Question Title * 13. Name of provider or practice Communication Preferences Question Title * 14. Preferred contact method: Phone call Text message Email Question Title * 15. Preferred time of day for contact: Morning Afternoon Evening Question Title * 16. Is it okay for us to leave a voicemail? Yes No Question Title * 17. How did you hear about the ICO4MCH Doula Program? Local health department Hospital or healthcare provider Social media Family or friend Community event Other (please specify) Question Title * 18. Have you already been connected with a doula through ICO4MCH? Yes No Question Title * 19. If yes, which doula are you currently connected with or prefer to work with? Aubrey Pickard Carla Shepherd Cashmere Ransom Kacie Egbert Sheneatha Bennett Tammy Mcneill Yanet Abreu N/A Consent Question Title * 20. Consent to Contact Yes No I consent to be contacted by the ICO4MCH Doula Program regarding doula services and understand that my information will remain confidential. Question Title * 21. Signature (type your full name) Question Title * 22. Date Done
