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Erie Niagara AHEC Mother-Doula Program Enrollment Form
NOTE:
We have currently reached capacity for this program. Our program has rolling admissions, so it is possible to still be able to participate in this program. We encourage you to fill out this form and we will contact you if a spot becomes available.
This form is to be completed by expectant mothers in Erie county who are willing to participate our 1 year doula and extended services program.
You must be a resident of Erie County, Black or Brown race, receive Medicaid-benefits, and be before 30 weeks gestation.
Please email with any questions <
mackley@en-ahec.org
>
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* Indicates required question
Email
*
Your email
First Name
*
Your answer
Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Phone Number (xxx) xxx-xxxx
*
Your answer
Home Street Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Ethnicity/Race
Check all that apply.
*
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Hispanic/Latinx
Other:
Required
Are you a permanent resident of Erie county?
*
Yes
No
Are you at 30 weeks or before?
*
Yes
No
What is your 1st language?
*
English
Spanish
Other:
What is your 2nd language?
*
English
Spanish
N/A
Other:
What trimester of your pregnancy are you currently in?
*
1st (1-13 Weeks)
2nd (14-27 Weeks)
3rd (28-40 Weeks)
When is your due date?
*
MM
/
DD
/
YYYY
Do you qualify/receive Medicaid benefits?
*
Yes
No
What company do you receive benefits through?
*
Independent Health
Fidelis Care
Excellus Health Plan (Univera)
Molina
Health Now
Well Care
United Healthcare
Blue Cross Blue Shield
Other
If other was selected in the previous question, please state your insurance provider.
*
Your answer
Are you willing to participate in this program for a full year after birth? If no, please explain.
*
Your answer
Are you willing to participate in maternal and infant health trainings? If no, please explain in "other" box.
*
Yes
No
Other:
Required
Do you have reliable transportation?
*
Yes
No
Will you require transportation assistance?
*
Yes
No
Other:
Do you have a reliable source of communication?
(i.e. phone, tablet, laptop, computer, etc.)
*
Yes
No
Is this your first pregnancy?
*
Yes
No
If this is not your first child, what number child is this?
*
Your answer
If you have a doula in our network that you would like to request, please indicate here.
Your answer
How did you hear about this program?
*
Your answer
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