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Confidential Client Intake Form

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 Alyssa at: (626) 388-2191 ext. 2 or Email: Alysss.Rogers@motherbabysupport.net

We aim to be receptive to our client's needs, so if you have a racial or ethnic preference for your doula, please let us know. Choose from drop-down menu.

Additional Questions Due to COVID-19

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.