Registration Form – Birth Doula – Mother's Care Doula Services, Inc.

REGISTRATION FORM: Birth Doula Services

WHAT HAPPENS AFTER I SUBMIT THIS REGISTRATION FORM? After submitting this Registration Form, you will be directed to an auto-generated message confirming your Form was submitted. MC will contact you within 72 hours to provide you with information about Doulas who are available to meet you for an interview. To learn more about Mother's Care and our Doulas CLICK HERE.

IS IT POSSIBLE TO MEET MORE THAN ONE DOULA? The number of Doulas you can interview is dependent on various factors including (but not limited to): specific requests you've included in your Registration Form and the availability of our staff during the time you will need assistance. We will do our best to introduce you to as many Doulas as possible but you will meet and interview at least one.

HOW WILL I MEET THE DOULA? All Interviews are conducted Virtually or by Phone. The Doula will contact you to coordinate the date and time of your appointment and the format you prefer to meet.

If you have more questions please email us: momsdoula@mcdsonlinedoulas.com or call us: 954-433-CARE (2273)

Title of the document

General Information About You:

Estimated Due Date:(Required)

Induction Date or Cesarean Date: (if applicable)

Your Full Name:(Required)

First Last

Your Partner or Spouse's Full Name:

First Last

Preferred Phone Number:(Required)

I consent to receiving text messages so MC or the Doula can communication with me:(Required)

Yes

You will NOT receive Marketing Information. Used as a form of communication to answer your questions, send updates or follow up with you regarding services.

Preferred Email:(Required)

You will NOT receive Marketing Information. Used as a form of communication to answer your questions, send updates or follow up with you regarding services.

Alternate Email:

Backup Email: You will NOT receive Marketing Information. Include if you would like us to copy your Partner in communication messages or use as your Backup Email.

Your Address: (Include Apt or Suite Number)(Required)

Street Address City State / Province / Region ZIP / Postal Code

Your Age:

How did you hear about Mother's Care?(Required)

Your Occupation:

Your Partner's Occupation:

Title of the document

Healthcare Provider & Birth Location:

Your OB and/or Midwife's Name:(Required)

Please include the Providers Full Name & Group/Practice Name

Birth Location Name:(Required)

(Hospital's Name, Birth Center Name or Home Birth)

BIRTH FACILITY/LOCATION: Are you aware of any restrictions related to having a Doula with you?(Required)

I have confirmed that I CAN have a Doula present.

I have confirmed that I CANNOT have a Doula present but I CAN have virtual assistance.

I am not sure but I will follow up with my Provider/Hospital.

I'm birthing in a Birth Center or at Home - There are no restrictions

If you do not know about possible restrictions, contact your Healthcare Provider or Birth Location immediately.

Tell us about your experience with your Healthcare Provider & Birth Facility so far:(Required)

Are you comfortable with your OB/Midwife and your Birth Location? Is there anything about your Provider or Birth Location you feel we should know?

Title of the document

FOR MEDICAID PATIENTS ONLY

I CONFIRMED THAT I WAS APPROVED BY MEDICAID TO HAVE DOULA SERVICES:

Yes

DOES MEDICAID PRE-COVER OR REIMBURSE ME FOR DOULA SERVICES? Until further notice, MC works with Medicaid by reimbursement ONLY. "Reimbursement" means that you are responsible to pay for Doula Services and later, file a claim with your insurance provider who will pay you back. CONTACT YOUR CARE MANAGER for specific information related to Medicaid coverage and whether your policy covers or reimburses for Doula Services.

FOR MEDICAID: Please send a copy of your Picture ID & Insurance Card to: momsdoula@mcdsonlinedoulas.com

Name of Your Insurance Company:

For Example: Sunshine Health, Blue Cross, United Healthcare, etc.

Member ID:

Group ID:

My Date of Birth:

Title of the document

Birth Doula Service Type:

TYPE OF SERVICE YOU PREFER:(Required)

Birth Doula (Traditional, In-Person Services)

Birth Doula (Virtual Services Only)

Birth Doula (Combo: In-Person & Virtual)

I'm not sure. I need help deciding.

FOR THOSE WITH A SEVERE FINANCIAL NEED:

Send me Info About Reduced Fees

Send me Info About Payment Arrangements

ARE CERTIFIED/EXPERIENCED DOULAS ALWAYS AVAILABLE? There may be occasions where a Certified Doula is not available. When this occurs we encourage you to consider working with an a "New Doula / Doula in Training".

I AM REQUESTING TO MEET A SPECIFIC DOULA:

Yes

DOULAS NAME & HOW YOU HEARD ABOUT HER:

AVAILABILITY & REQUESTING A SPECIFIC DOULA: We will make every intention to meet your need to work with the Doula you've requested however, we cannot guarantee that your requested Doula is available. If she is not, we will introduce you to another Doula from our experienced team.

Title of the document

More About You & Pregnancy History:

I am currently expecting:(Required)
One Baby
Twins
Multiples

Is this your First Pregnancy?(Required)
Yes
No

(If comfortable sharing): What are the Names & Ages of your other children?

MY PREVIOUS BIRTH EXPERIENCE

If this is not your first baby, and you feel comfortable sharing, in the box below please describe your previous birth experience.

MY PREVIOUS BIRTH EXPERIENCE:
CLICK HERE for details you can provide about your Previous Birth Experience that feel are important for us to know.

Title of the document

More About You & Pregnancy History:

Have you taken or plan to take Prenatal Education Classes?(Required)
Yes - I have taken or I am registered to take Prenatal Classes.
No - I have not taken Prenatal Classes and not planning to at this time.
No - I have not taken Prenatal Classes but would like to. Please send me information on MC's Prenatal Education Classes
MC offers Childbirth Preparation, Breastfeeding, Newborn Care, and many other classes! CLICK HERE for info about our Prenatal Classes.

HEALTH & SAFETY: Please share any health related special circumstances in your history or that you are currently experiencing:(Required)
IMPORTANT - Please CLICK HERE for Information related to Health & Safety.

Title of the document

Your Birth Preferences, Goals & Doula Specifics:

BIRTH PLANNING: Do you have a "Birth Plan"?(Required)
Yes - I have a Birth Plan.
No- I do not have a Birth Plan but I would like help writing one.
No - I do not have a Birth Plan & prefer not to write one.
Need help creating a Birth Plan? Visit: "Lamaze - Forming Your Birth Plan" or "Spinning Babies: Creating Your Birth Plan".

ABOUT YOU: Tell us about you, your partner (if applicable), and your pregnancy experience so far:(Required)
CLICK HERE for details we'd like to know about you! Details may help us connect you with the right Doula.

ABOUT YOUR DOULA: What traits, characteristics, knowledge and/or experience do you expect your Birth Doula to have?(Required)
In a potential Doula, what type of personality / character would work best with you?

MEDICAL INTERVENTIONS & PAIN MANAGEMENT: Do you have preferences or goals you wish to share?(Required)
CLICK HERE for details information about common medical interventions, pain medications & management and questions about your goals & preferences.

ADDITIONAL INFO ABOUT YOU: Anything else you need to share?(Required)
CLICK HERE to add Additional Information about you that you feel is very important for us to know.

Title of the document

PLANNED VAGINAL BIRTH AFTER PREVIOUS CESAREAN (VBAC):

VBAC INFORMATION: I am Planning for a Vaginal Birth After a Previous Cesarean:

No - I am not planning for a VBAC.

Yes - My goal is to have a VBAC.

I'm not sure - What's a "VBAC"?
CLICK HERE for details about VBAC (Vaginal Birth After Cesarean).

To learn more about VBAC and whether you are a good candidate for one visit: Are you an Ideal Candidate for VBAC // Is Your Provider VBAC-Friendly? // Questions to Ask Your Provider about VBAC // How to Have a Successful VBAC // All things VBAC (VBACLink)

Title of the document

CLIENT CONFIDENTIALITY & CONSENT STATEMENT:

Confidentiality of medical and personal information obtained during the course of the Doula’s work is of the utmost importance. Due to current confidentiality regulations we must have a signed your permission to collect any information about you that includes: your contact info, details about your current or previous pregnancies, previous birth experience(s), your current labor, birth, postpartum plans, info about your spouse/partner and family (children) and any other information you've included in this Registration Form. We will keep a copy of this Confidentiality & Consent Form to demonstrate that Mother’s Care and your Doula are indeed complying with the confidentiality regulations if questioned. Failure to comply with these confidentiality regulations could result in penalties.

I authorize Mother’s Care Doula Services, Inc. (MC), which includes the Doula I will ultimately work with and the MC Backup Doula Support Team, to take notes about me, including personal information I included in this Registration Form and any other information about me that I choose to disclose including but not limited to: my contact info and the contact info of anyone I included in this form (phone numbers, emails, addresses), information regarding my health history and or current health, details regarding previous pregnancies and birth experiences and this current pregnancy, my plans, goals and preferences for labor, birth and postpartum, information I share about my spouse or partner and or other close or extended family members, children and or friends and acquaintances.

I authorize MCs Service Coordinators to collect the information in the Registration Form and use it to help me select the best Doula for me and later to be used by my Primary Doula and MCs Backup Doula Staff. This information might also be used to provide me with a summary of my birth experience for my own personal use if I request it.

I understand that the information contained in this Registration Form will not be shared with anyone outside of MCs Leadership & Doula Staff unless I give authorization and consent (see below).

IF REQUIRED FOR DOULA CERTIFICATION OR RECERTIFICATION: I authorize MC to share the following information with DONA International for the purpose of Doula Certification (if I work with a Doula in Training) or Recertification (if I work with a Certified / Experienced Doula): the date of my baby's birth, state my baby was born in, what comfort measures and strategies for labor and birth were used, and medical interventions and or medications that were used, the outcome of the birth (vaginal or cesarean) and the fact that I hired and worked with a Birth Doula.

WILL MY PERSONAL IDENTIFYING INFORMATION BE SHARED WITH DONA INTERNATIONAL OR ANYONE OUTSIDE OF MC? I understand that NONE of my personal contact information or my identity including my name, phone numbers, address, emails, name of my spouse/partner, children or other personal identifying information will NOT be shared with anyone outside of MC and will be kept anonymous.

I understand that if I have any questions / concerns about how the information contained in this form is used I can email MC at momsdoula@mcdsonlinedoulas.com or contact MC at: 954-433-CARE (2273).

Title of the document

SUBMIT MY REGISTRATION FORM!

CAPTCHA ANTI-SPAM

WHEN YOUR FORM IS RECEIVED:
An MC Representative will contact you within 72 hours.
These forms are copyrighted and cannot be copied/used/reproduced without the written authorization of Mother's Care Doula Services, Inc.

Name
This field is for validation purposes and should be left unchanged.

Private Interview: Birth Doula Service

REGISTRATION FORM: Birth Doula Services

General Information About You:

Healthcare Provider & Birth Location:

Birth Doula Service Type:

More About You & Pregnancy History:

More About You & Pregnancy History:

Your Birth Preferences, Goals & Doula Specifics:

PLANNED VAGINAL BIRTH AFTER PREVIOUS CESAREAN (VBAC):

CLIENT CONFIDENTIALITY & CONSENT STATEMENT:

SUBMIT MY REGISTRATION FORM!

Private Interview:
Birth Doula Service