Doula Provider Services - Inbound Referrals

This form is for care provider and social service agency referrals to Happy Mama.

Thank you for helping provide a continuum of support for those in need of doula support services. Please complete the form below as thoroughly as possible. *An asterisk indicates a required field.

Press Submit when complete. You may also fax this form to +1 (858) 430-5551

Should you have any questions, you may call our office at 619-800-6443 or email us at info@happymama.global.

For more details about Happy Mama, visit https://happymama.global

REFERRED BY

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* 1. Name of referring clinic/agency?

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* 2. Address 1

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* 3. Address 2

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* 4. City

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* 5. County

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* 6. State

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* 7. Clinic/Agency Contact Name of Person Making the Referral

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* 8. Clinic/Agency Contact Phone Number

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* 9. Clinic/Agency Contact Email Address

CLIENT DETAILS

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* 10. Client's First Name

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* 11. Client's Last Name

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* 12. Client's Preferred Name

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* 13. Preferred Pronoun(s)

She/her

He/his

They/Their

Other (please specify)

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* 14. Date of Birth (MM/DD/YYYY)

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* 15. Client's Primary Phone Number (type N/A if not available or DK if unknown)

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* 16. Alternative Phone Number

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* 17. Client's Email Address (type DK is unknown)

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* 18. Client's Street Address (type DK if unknown)

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* 19. City

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* 20. State

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* 21. Zip Code

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* 22. Number of Weeks Pregnant? (Or enter DK, If unknown)

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* 23. Service Type Requested

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* 24. Insurance

Medicaid

Tricare

Private Insurance

Private Pay / Uninsured

Unknown

Other (please specify)

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* 25. CLIENT INSURANCE INFORMATION

PRIMARY Insurance Information

Policy Number

Group Number

Subscriber Names

Subscriber Date of Birth

SECONDARY Insurance Information

Secondary Policy Number

Secondary Group Number

Secondary Subscriber Names

Secondary Subscriber Date of Birth

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* 26. Preferred Language

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* 27. Will an interpreter be needed at intake?

Yes

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* 28. Does the client identify as part of any of these communities:

African / African American

Asian / Asian American

Hawaiian / Samoan / Pacific Islander

Native American / Alaskan Native

Southeast Asian

White / Caucasian American

Unknown

Other (please specify)

PREGNANCY HISTORY

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* 29. Name of Primary Care Physician

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* 30. Provide the Primary Care Physician's Phone Number if Different from Referring Agency

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* 31. Name of Obstetrician or Midwife

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* 32. Provide the Obstetrician or Midwife's Phone Number if Different from Referring Agency

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* 33. Name of hospital/birth center currently scheduled

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* 34. Estimated Due Date? (MM/DD/YYYY)

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* 35. Select any of the following that currently applies:

Anemia

Anxiety

Blind

COVID-19

Deaf / Hearing Impaired

Depression

Domestic Violence

Gestational Diabetes

HIV / AIDS

Hypertension

LGBTQ2S+

Migratory Farmworker

Multigravida

Multiple pregnancy

Obesity

Primigravida (First-time Pregnant)

Preeclampsia

Rainbow Baby

Refugee

Substance Abuse

Surrogate Pregnancy

Teen Pregnancy

Type I or II Diabetes

VBAC

Unknown

Other (please specify)

None of the above

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* 36. Any additional past or ongoing symptoms during this pregnancy?

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* 37. Is the client presently enrolled in any of the following programs?

Black Infant Health

Cal-Fresh

Cal-SAFE

CalWORKs

First 5

Healthy Start

WIC

Unknown

Other (please specify)

None of the above

Doula Provider Services - Inbound Referrals

Question Title

* 1. Name of referring clinic/agency?

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* 2. Address 1

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* 3. Address 2

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* 4. City

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* 5. County

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* 6. State

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* 7. Clinic/Agency Contact Name of Person Making the Referral

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* 8. Clinic/Agency Contact Phone Number

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* 9. Clinic/Agency Contact Email Address

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* 10. Client's First Name

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* 11. Client's Last Name

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* 12. Client's Preferred Name

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* 13. Preferred Pronoun(s)

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* 14. Date of Birth (MM/DD/YYYY)

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* 15. Client's Primary Phone Number (type N/A if not available or DK if unknown)

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* 16. Alternative Phone Number

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* 17. Client's Email Address (type DK is unknown)

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* 18. Client's Street Address (type DK if unknown)

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* 19. City

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* 20. State

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* 21. Zip Code

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* 22. Number of Weeks Pregnant? (Or enter DK, If unknown)

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* 23. Service Type Requested

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* 24. Insurance

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* 25. CLIENT INSURANCE INFORMATION

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* 26. Preferred Language

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* 27. Will an interpreter be needed at intake?

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* 28. Does the client identify as part of any of these communities:

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* 29. Name of Primary Care Physician

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* 30. Provide the Primary Care Physician's Phone Number if Different from Referring Agency

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* 31. Name of Obstetrician or Midwife

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* 32. Provide the Obstetrician or Midwife's Phone Number if Different from Referring Agency

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* 33. Name of hospital/birth center currently scheduled

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* 34. Estimated Due Date? (MM/DD/YYYY)

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* 35. Select any of the following that currently applies:

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* 36. Any additional past or ongoing symptoms during this pregnancy?

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* 37. Is the client presently enrolled in any of the following programs?

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* 38. Additional Information