CONFIDENTIAL CLIENT INTAKE FORM
HIPAA Privacy and Disclosure Statement
Are you wondering how your information will be used? The information in this form will be shared with our Doula Program Coordinator for the purpose of matching you to the best Doula to meet your needs. We will also share this information with your Doula for the purpose of providing you with the best care. We may also use this information for statistical purposes to ensure program quality and reporting to our funders. Your name and identifying information will not be shared.
By completing the form below, you agree to have your information shared by these persons. If you have any questions or concerns about your information, please contact our HIPAA Compliance Officer, Robert at: firstname.lastname@example.org.