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Subsidized Labor Doula Services Application
Fill out this form to apply for subsidized doula services provided by members of the Utah Doula Association. PLEASE NOTE we will NOT be able to match you with a specific doula.
* Indicates required question
Email
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Your email
Name
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First and last name
Your answer
Your Date of Birth
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MM
/
DD
/
YYYY
Baby's Estimated Due Date. (Please allow at least 8 weeks before your due date)
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MM
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DD
/
YYYY
Phone number
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Your answer
What city do you live in?
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Your answer
Where do you plan to deliver?
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Your answer
Who is your doctor/midwife?
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Your answer
Do you currently have a doula?
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Yes
No
Other:
Type of Services-Currently most services may be virtual based on hospital policy. If your hospital/place of birth limits doula support to virtual only are you still interested in receiving support?
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Yes, I would like support for virtual services specifically at this time.
Yes, I would like support for either in-person or virtual services.
No, I am not intersted in virtual services but would still like in-person services if my birth place allows it.
Other:
Do you have an FSA or HSA?
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Yes
No
Why are you applying for discounted services? The more details you provide, the better we can evaluate your application.
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Your answer
What number of pregnancy is this?
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Your answer
If you have had a previous pregnancy, what was the outcome of the pregnancy/birth?
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Your answer
What amount could you contribute toward doula services? This could either be a financial contribution or trade. If you have something to trade, please indicate a monetary value along with the offering.
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Your answer
Have you taken a childbirth education class this pregnancy? If so, what class and where?
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Your answer
Any other considerations we should take into account
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Your answer
How did you hear about this program?
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Your answer
Are you willing to write a review after the birth?
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Yes
No
Send me a copy of my responses.
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