Doula Program Sign-Up: Current YWRC Participants

I am interested in being part of the YWRC's Better Beginnings Doula Program.
- Yes
- No
- Maybe - would like more info.
Participant Name*
First Last
Participant Date of Birth*
Date Format: MM slash DD slash YYYY
Participant Age*
Participant Email
Enter Email Confirm Email
Participant Facebook Name
(Participants can join a Young Moms group on Facebook as one way to get connected.)
Participant Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Gender*
- Cis Female
- Trans Female
- Non-binary
- Other Gender(s)
- Prefer not to answer
Race*
Do you identify as Latina/Latinx/Latino?*
- Yes
- No
Do you identify as LGBTQIA+?*
- Yes
- No
- Prefer not to answer
What program(s) are you currently participating in?*
- Childbirth Education Group
- Individual Support Program
- Parenting and Life Skills Group
- Young Moms High School Group
Do you require transportation to/from the YWRC program(s)?*
- Yes
- No
Do you currently in school?*
- Yes
- No
If you are attending school, what is the name of the school/program and what grade/level are you currently in?
Pregnancy Information
When is your due date?
How many times have you been pregnant, including currently?
Do you have any children in addition to this pregnacy?
- Yes
- No
If you have additional children, please list your child/children's names, ages and any allergies they have.
Where do you plan to deliver?
Your Dr./OB/Midwife Name:
When was your first prenatal visit?
- 1st Trimester
- 2nd Trimester
- 3rd Trimester
- Haven't had one yet
Are you taking Prenatal Vitamins?
- Yes
- No
How do you plan to feed your baby?
- Breast/chest-feeding
- Formula
- Both
Do you drink alcohol now?
- Yes
- No
If you drink alcohol now, how much?
- 1 drink per day
- 2 or 3 per day
- More than 3 per day
- Occasionally
Do you currently smoke?
- Yes
- No
If you currently smoke, how many?
- 1 - 4 per day
- 5 - 12 per day
- 13 - 20 per day
- Occasionally
Who are your support people during pregnancy, labor and birth?
What are your greatest concerns about this pregnancy? Please be specific.
How do you feel a doula can be the most beneficial to you?
Are you employed/do you work?
- No
- Yes, Full-time
- Yes, Part-time
If you do work/are employed, how much do you make in a year?
- $0 - $5,415
- $5,416 - $9,424
- $9,245 - $10, 829
- $10,830 - $13,429
- $13,430 - $16,137
- $16,138 - $18,844
- $18,845 - $19, 927
- $19,928 - $21,559
- $21,560 - $32,389
- $32,390 - $43,319
- $43,320 - $54,149
- $54,150 or higher
Do you receive any of the income/benefits listed below? If so, select all that apply.
- Child Support
- Family Investment Program (FIP)
- General Assistance
- SNAP/EBT
- Social Security Disability
- Supplemental Security Income
- TANF
- Unemployment
- Women, Infant, and Children (WIC)
- Other
- No Other Income Sources
Do you have any allergies?
- Yes
- No
If you have any allergies, please list them here:
I have answered these questions to the best of my knowledge. If I have any questions or concerns, I will speak with the program facilitator(s).
Participant Name/Signature*
First Last
Date Signed*
Date Format: MM slash DD slash YYYY
Participant Signature*
First Last
Phone
This field is for validation purposes and should be left unchanged.

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Doula Program Sign-Up: Current YWRC Participants

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