Citywide Doula Initiative - The Mothership
Thank you for your interest in doula from The Mothership & The Citywide Doula Initiative. Please provide the following information and we will be in contact shortly.
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Email *
Name *
Are you a resident of one of the following zip codes: Manhattan: 10025, 10026, 10027, 10029, 10030, 10031, 10032, 10033, 10034, 10035, 10037, 10039, 10040 Bronx: 10454, 10457, 10467 *
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Phone Number *
Street Address *
Date of Birth  *
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Gender
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Are you currently eligible for Medicaid? *
Are you currently pregnant? *
Emergency Contact Name & Phone Number
If currently pregnant, please indicate which number pregnancy this is for you. *
What is your estimated due date? *
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Have you previously worked with a doula?
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Where is your intended place of birth (hospital name, home, etc)?
Who is your care provider?
How is your prenatal care going?
Are there any concerns you are facing during this pregnancy?
What experiences (if any) have you had related to childbirth? How has this shaped your current view?
What is your vision (if any) for the birth and postpartum period?
What qualities are you looking for in a doula?
What is your preferred language?
Please describe yourself, your current pregnancy, and why you’re a great candidate for the Citywide Doula Initiative.
How did you hear of us?
Do you have a preference between unvaccinated and vaccinated (COVID) doulas?
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