It Takes a Village!

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It Takes a Village!

Let's pull together to give you the best possible experience you can have during your perinatal journey! Harambee Village Doulas provide social, emotional, physical and educational support throughout your pregnancy, labor, postpartum and beyond.

Thank you for your interest in working with Harambee Village. You will hear back from our intake specialist within 7-10 days . Please note that submitting a referral does not guarantee services. If a referral is submitted after 32 weeks of pregnancy, we cannot guarantee we are able to process an appropriate referral in that timeframe, but we are always doing are best to serve everyone!

If you have an urgent matter please call our office at (608) 298-7720. Do not send in an online referral for urgent matters! If you have any questions please send us an email at info@harambeevillage.org.

Are you a pregnant parent, a provider, or a Harambee Partner Organization *

Desired Services: *

Birth Doula Services

Postpartum Doula Services

Breastfeeding Support

Breastfeeding Education

PNCC @ the Village

Family Support Programming at our Family Resource Center

Monthly Support Groups

Midwife prenatal & postpartum care

Required

If you are a provider, or HVD partner organization, does your client know you are making this referral? *

Yes

If you are a provider, or HVD partner organization, please specify the project you are referring to or your affiliation with Harambee below: *

Name of Person filling out this form *

Email of person filling out this form *

Phone number of person filling out this form *

Birthing Person First Name *

Birthing Person Last Name *

Birthing Person Date of Birth *

YYYY

Estimated Due Date or Date baby was born *

YYYY

Current gestational age of birthing person (how far along are you in your pregnancy)

Is this pregnancy considered a high risk pregnancy? *

Yes

Other:

If you answered yes or other above, please explain *

Email of birthing person *

Phone number of birthing person *

Please indicate your race/ethnicity below: *

City where birthing person lives *

Name of Insurance *

Are you on badger care *

Yes

Insurance Number

Which clinic are you receiving your prenatal care? *

Are you interested in meeting with our Midwife at our Harambee Birth & Family Center Clinic? *

Yes

Tell me more

The best way to contact the birthing person: *

Phone Call

Text Messaging

Required

Client will be giving birth at: *

Do any of the following apply to you, or your client? *

Low Income (200% of Federal Poverty Guidelines or less)

Badgercare eligible

WIC eligible

Homeless

19 years old or younger

Client or partner is on active duty in the military

LGBTQIA+

None of the above

Required

What are your preferred pronouns?

Have you come in contact with anyone with COVID-19 in the last 14 days? *

Yes

Have you tested positive for COVID-19 during your pregnancy? *

Yes

Have you ever tested positive for COVID-19? *

Yes

Have you experienced chills, fever, or any other symptoms of COVID-19 in the last 14 days? *

Yes

Have you traveled out of the state in the last 30 days? *

Yes

If you are the pregnant person, how do you plan to pay for your doula services? *

Out of Pocket

Unsure and would like to discuss with someone

Other:

If you selected "other" as a payment option above, please explain below: *

Is there anything else you would like us to know about you or the person you are referring for services? *

Please write your initials below to declare that the information you have provided is accurate and complete. *

Submit

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