Community Birth Assistance Services

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Please note that our community program may involve doula students who will sit in on appointments for training purposes.

Name *

Email *

Full Address *

Phone number *

DOB *

YYYY

Do you identify as a Black Woman? *

Yes

If you do not identify as a Black Woman; please list any risk factors that would make you eligible for this program.

If you do not identify as a Black Woman, are you prepared to accept the service fee of 1% of your income? (Payment plans are allowed) *

Yes

N/A

Are you giving birth in.... *

Atlanta, GA

Augusta, GA

Are you planning a homebirth, that you would like help affording? *

Yes

Do you have transportation? *

Yes

How did you hear about this program? *

This short application does not guarantee your acceptance to receive service. You will be required to book a (free) 30-minute virtual consultation , where you will provide any necessary documents, payments, etc. You will be notified by email and phone to let you know what documents may be needed, and to schedule your consultation. Do you understand? * *

Yes

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