Confidential Client Intake Form

English English French French Spanish Spanish

INITIAL CLIENT CONFIDENTIAL INTAKE FORM

Our services are available for everyone, on a sliding scale. We serve everyone, regardless of ability to pay. Low-income families and those with Medi-Cal may receive volunteer or low-cost services, because we believe EVERY family deserves a Doula and quality childbirth education.

Questions? Call J. Tranae at: (626) 388-2191 ext. 2 or Email: J.Tranae@motherbabysupport.net


Para recomendar a alguien o inscribirse, complete nuestra Solicitud Para Padres de Servicios de acompañantes durante el parto (Doula) y Lactancia, o llame a Lisa Mejia al (213) 379-0544 o envíe un correo electrónico a: Lisa.Mejia@motherbabysupport.net

HIPAA Disclosure: Are you wondering how your information will be used? The information in this form will be shared with our Doula Program Coordinator and Community-Based Doula Program Director 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 possible. By completing the form below, you agree to have your information shared by these persons. You may also request that your information not be stored on our HIPAA-compliant website. Our doulas and staff are trained and certified to protect your Healthcare Information (PHI) as required by HIPAA. If you have any questions or concerns about your information, please contact our HIPAA Compliance Officer, Robert at: security@motherbabysupport.net.