Raíces para el Cambio Cooperative – Community Doula Services Form for Clients with Quartz Health Insurance

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)

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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?

Yes

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* 6. Phone Number

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* 7. Email Address

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* 8. Weeks of Gestation

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* 9. Are you pregnant with

Singleton

Twins

Triplets

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* 10. Number of Gestations (including current pregnancy)

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

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* 12. Primary Prenatal Care Provider/Clinic

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* 13. Hospital/Birthing Center Planned for Delivery

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* 14. Quartz Health Insurance Member ID

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* 15. Group Number (if applicable)

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* 16. Primary Insurance Holder Name

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

Prenatal Visits

Labor and Birth Support

Postpartum Visits

Breastfeeding Support

Services not covered by Quartz Health Insurance

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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.

I accept

I do not accept

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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

Male

Female

Non-binary

Prefer not to say

Other