Inquiry Form - (in person services) birth, postpartum, bereavement, abortion doula placenta encapsulation & lactation support Name * First Name Last Name Pronouns Email * Phone * (###) ### #### City of residence * Estimated due date Required for birth, postpartum, and placenta services MM DD YYYY (if applicable) Planned birthing location (if applicable) Who is your doctor or midwife/practice? Required for birth support Services of interest * Birth Support Postpartum Support Bereavement Support Termination Support Placenta Encapsulation/keepsakes Lactation Support At this time, I am only able to provide in home support to families in which all adult members have been fully vaccinated against COVID-19 (does not apply to placenta services). * I understand and confirm all eligible adult members of our family have received the initial two dosages (or one dosage of J&J). One or more members of my family have chosen not to be vaccinated, but I am interested in a referral to another doula who can accommodate me. not applicable Please list several dates and times over the next two weeks that work well for a free 30 minute virtual service consultation: * (all family members/support partners/beloveds are welcome to attend) How did you hear about me/my services? * Thank you for reaching out! I look forward to connecting with you soon.Due to the nature of birth work, responses & confirmations may come at odd hours or with some delay. I am grateful for your patience and understanding. Due to the nature of birth work, responses & confirmations may come at odd hours or with some delay. I am grateful for your patience and understanding.
