Thank you for your interest in our community-based doula services. All information is confidential.

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1. Full Name

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2. Home Address

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3. Zip Code

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4. Your date of birth (MM/DD/YYYY) (Required.)

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5. Do you identify as Latina/e/o, Afro Latina/e, Asian Latina/e heritage Latina/e and/or Indigenous People from Latin America? (Required.)

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6. Phone Number

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8. Weeks of Gestation

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9. Are you pregnant with (Required.)

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10. Number of Gestations (including current pregnancy) (Required.)

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11. Expected Due Date (MMM/DD/YYYY). If not known, type: NK (Required.)

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12. Primary Prenatal Care Provider/Clinic (Required.)

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13. Hospital/Birthing Center Planned for Delivery (Required.)

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14. Quartz Health Insurance Member ID (Required.)

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15. Group Number (if applicable) (Required.)

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16. Primary Insurance Holder Name (Required.)

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17. Which services are you interested in? Select all that apply

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18. By completing this form, I give permission to Raíces para el Cambio Cooperative to use and share my information, as needed, to refer me and provide doula services. I also authorize them to contact me to schedule services and share program information by phone, text message, or email.

I may withdraw my consent at any time by requesting that communication and use of my information stop. (Required.)

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19. Please type your name to complete the intake and certify your consent to be contacted.

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20. Gender

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