Doula Training Verification Form

Doula Training Verification Form

A staff person at the training organization is being asked to complete this form to verify that the doula certification applicant has successfully completed a doula training with your organization. This training verification form is being submitted by the applicant to the Illinois Medicaid-Certified Doula Initiative. By submitting this document, the person completing the document is attesting that all information is true and accurate.

Applicant's Information

Name of Doula/Trainee who Completed the Training.*

Doula/Trainee's Address*

Doula/Trainee's City*

Doula/Trainee's State*

Doula/Trainee's Zip*

Doula/Trainee's Email*

Training Agency

Name of Doula Training Agency*

Name of Staff Person Completing this Form*

Title of Staff Person Completing this Form*

Email of Staff Person Completing this Form*

Training Organization Address*

Training Organization City*

Training Organization Zip Code*

Training Organization Phone Number*

Phone

Training Components

Training Components*

(Check all training components that were provided in your organization's training program to the doula certification applicant)

Select or enter value

Face to Face Work with Clients*

Select or enter value

Verification Details

Title of Training Program*

Participating Health Care Organization 1

Fill in this information if the training program collaborated with a health care organization. Skip these questions if they are not applicable.

Organization 1 Address

Organization 1 Phone

Organization 1 Contact person

Participating Health Care Organization 2

Organization 2 Address

Organization 2 Phone

Organization 2 Contact Person

Participating Health Care Organization 3

Organization 3 Address

Organization 3 Phone

Organization 3 Contact Person

Date Applicant completed the training program*

Signature*

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