Name *

First Name

Last Name

Best way to contact you *

Phone

Email

Text Message

Client Date of Birth

MM

DD

YYYY

Estimated Due Date

MM

DD

YYYY

I am applying for: *

Birth Doula Services

Postpartum Doula Services (Daytime)

Postpartum Doula Services (Overnights)

Birth + Postpartum

Do you identify as Black, Indigenous or a Person of Color? *

Yes

No

Do you identify as Queer or Trans?

Yes

No

Price Point *

Please choose the option which most resonates with you and the financial circumstances you currently find yourself in. We will discuss this in more detail based on the answer you provide in our initial consultation. Please consider that while this is based on the honor system, I do reserve pro-bono work to black and brown families, queer and trans folks of color and otherwise on a case by case basis.

I am financially sound and secure in monetarily being able to meet my basic needs/have access to surplus money and/or wealth and can afford and am happy to pay the full fee.

Would like to inquire about payment plans, I can afford your full fee but not all at once and would ask for flexibility.

I would like to inquire about sliding scale, I can offer some monetary exchange but not the full fee.

I struggle to financially meet my basic needs. I know I want the support of a doula but absolutely cannot afford to give monetarily at this time.