Discounted Fees Eligibility Form
If you are unable to pay the advertised fees for Doula services you may apply for a discounted fee based upon your income. Please complete this form in its entirety for review. I will contact you to discuss a fee that appropriately reflects your situation.
Your answers will be kept on file and in strict confidence.

**PLEASE NOTE THAT YOU MAY BE ASKED FOR A COPY OF 1040 OR A FEDERAL TAX FORM TO VERIFY INCOME**
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Name (First & Last) *
D.O.B
MM
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DD
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YYYY
Estimated Due Date *
MM
/
DD
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YYYY
Are you currently employed? *
Do you work seasonally only? *
How much money do you and all who live in your household bring in per month? *
If you are not working, how are you meeting your monthly expenses? *
Do you have health insurance? *
Do you have MediCal? *
Are you paying out of pocket for your prenatal/birth provider? *
Please list all that you & those living in your household receive: *
Required
Please tell me why you would like financial assistance *
Please tell me how much you have budgeted for Doula services. *
I would like to consider a custom Payment Plan *
PLEASE READ AND SIGN
I attest that the information disclosed above is true and accurately reflects my current financial situation and that I do not have adequate personal resources that may be utilized to meet my fees for doula services. I understand that the information given above will be kept confidential except for the purposes noted above and not be released without my written permission.
Signature (First & Last) *
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