EOCCO Doula Referral Form

EOCCO Doula Referral Form

If a pregnant member requests a Birth Doula, please complete the form below, and the THW Liaison will reach out to the patient (unless noted otherwise) to start the doula matching process.

Please share with us the due date and any other information that will help us find the best possible match for their care.

For questions, please contact THW@eocco.com.

Patient Information

Patient First Name*

Patient Last Name*

Patient Date of Birth*

Medicaid Number*

What county does the patient live in?*

This will help match the patient with a doula nearby.

Select or enter value

Patient Address

City

State

Zip Code

Patient Contact Information

NOTICE! EOCCO must have a way to contact the patient. This can be through their email, phone, or the referrer. If the patient does not have an email or phone number, please note how EOCCO should contact the patient.

Patient Preferred Language*

Select or enter value

Other language*

Patient Email

Patient Phone Number

Phone

Is it okay for EOCCO to contact this patient?*

Select or enter value

Please indicate the hours that are appropriate to contact the patient.*

How should EOCCO get in contact with this patient? Please explain.*

Pregnancy Information

Patient EDD (Estimated Due Date)*

Date of 1st Prenatal Visit*

If no prenatal visits have occured, please enter 12/31/1999.

Where is the patient planning on giving birth?*

Patient's PCP/OBGYN/Midwife

Comments/Notes

Does the patient need accommodations?*

For example, interpreters, resource screenings, etc.

Select or enter value

Please describe the patient's needed accommodations*

Referrer Information

"Referrer" means the person filling out this form, including clinics, providers, community partners, individuals, and other organizations.

Referrer Name*

First and Last Name

Referrer Email*

Referrer Phone Number

Phone

Relationship to Patient*

Select or enter value

Would you, as the referrer, like a follow-up when the patient has been matched to a birth doula?*

You will receive the follow-up via the contact information you provided.

Select or enter value

Send me a copy of my responses

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