Doula CertificationIllinois Medicaid-Certified Doula Initiative

Doula Certification

Illinois Medicaid-Certified Doula Initiative

Please make sure you have all your information and documentation ready before you begin. After your application has been submitted, if there are missing documents or if SIU needs more information from you, then you will receive an email with instructions for submitting additional information.

Personal Information

Name*

Email*

Date of Birth*

Residential address*

City*

State*

Zip*

Phone*

Phone

Contact Permissions

Permissions to send emails/ texts related to your Doula application.

Contact Permission Via Email*

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Contact Permission Via Phone*

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Demographics

Your Gender*

Your Race/Ethnicity*

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Your Education Level*

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Your Primary Career*

How many births do you work on average per month?*

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Which best describes your work status as a doula?*

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Name of organization you work for as a doula?*

Illinois counties where you have worked as a doula*

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Illinois counties where you intend to work*

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Verification & Requirements

Application Pathway Requirements*

Read the descriptions below and then select the appropriate application pathway from the dropdown menu that applies to your experience working as a doula.

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Training Program Pathway, 3-1-1: This pathway is for applicants who completed a formal training program within the past five years.

You will need to report 3 birth experiences
Within past 1 year from today
And 1 birth experience reference submits an Experience Verification Form on your behalf (the birth occurred 1 year from today).

Legacy Pathway, 5-3-3: This pathway is for applicants who have not completed a formal doula training program within the past five years, OR who have birth experiences from more than one year from today.

You will need to report 5 birth experiences
Within past 3 years from today
And 3 birth experience references submits an Experience Verification Form on your behalf (the birth occurred 3 years from today)..

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*NOTE: ALL applicants are required to have training in HIPAA, Trauma-Informed Care, CPR or BLS, Implicit Bias or Cultural Competency, and Anatomy & Physiology of pregnancy and birth.*

Select your pathway.

Select or enter value

Training Organization*

Please indicate the training organization where you completed your training. If your training organization is not listed, please select "Other - training organization not listed" at the bottom of the list.

Select

Documentation for BA NIA Incorporated*

Upload your BA NIA training certificate here.

PLEASE CHECK THIS BOX to reveal the File Upload field.

Documentation for BIPOC for Better Birth*

Upload documentation of the following 2 items:

Your training certificate
Current CPR or Basic Life Support certificate

PLEASE CHECK THIS BOX to reveal the File Upload field.

Documentation for Birth & Baby University*

Upload documentation of the following 3 items:

Your training certificate
Current CPR or Basic Life Support certificate
Documentation of HIPAA training

PLEASE CHECK THIS BOX to reveal the File Upload field.

Documentation for Birth Arts International*

Upload documentation of the following 4 items:

Your training certificate
Documentation of HIPAA training
Documentation of Trauma-Informed Care training
Current CPR or Basic Life Support certificate

PLEASE CHECK THIS BOX to reveal the File Upload field.

Documentation Birthing Advocacy Doula Training*

Upload documentation of the following 4 items:

Your training certificate
Documentation of HIPAA training
Documentation of Trauma-Informed Care training
Current CPR or Basic Life Support certificate

PLEASE CHECK THIS BOX to reveal the File Upload field.

Documentation for Birth With Spirit*

Upload your Birth With Spirit training certificate here.

PLEASE CHECK THIS BOX to reveal the File Upload field.

Documentation for Birthworks*

Upload documentation of the following 4 items:

Your training certificate
Documentation of HIPAA training
Documentation of Trauma-Informed Care training
Documentation of Implicit Bias/Cultural Competency training

PLEASE CHECK THIS BOX to reveal the File Upload field.

Documentation for Charis Childbirth*

Upload documentation of the following 5 items:

Your training certificate
Documentation of HIPAA training
Documentation of Trauma-Informed Care training
Current CPR or Basic Life Support certificate
Documentation of Implicit Bias/Cultural Competency training

PLEASE CHECK THIS BOX to reveal the File Upload field.

Documentation for CAPPA*

Upload documentation of the following 4 items:

Your training certificate
Documentation of HIPAA training
Documentation of Trauma-Informed Care training
Current CPR or Basic Life Support certificate

PLEASE CHECK THIS BOX to reveal the File Upload field.

Documentation for Childbirth International*

Upload documentation of the following 4 items:

Your training certificate
Documentation of HIPAA training
Documentation of Trauma-Informed Care training
Current CPR or Basic Life Support certificate

PLEASE CHECK THIS BOX to reveal the File Upload field.

Documentation for CCI*

Upload documentation of the following 3 items:

Your training certificate
Current CPR or Basic Life Support certificate
Documentation of Implicit Bias/Cultural Competency training

PLEASE CHECK THIS BOX to reveal the File Upload field.

Documentation for Cornerstone Birthwork Training*

Upload documentation of the following 3 items:

Your training certificate
Documentation of HIPAA training
Current CPR or Basic Life Support certificate

PLEASE CHECK THIS BOX to reveal the File Upload field.

Documentation for DONA*

Upload documentation of the following 2 items:

Your training certificate
Current CPR or Basic Life Support certificate

PLEASE CHECK THIS BOX to reveal the File Upload field.

Documentation for Doula Alliance*

Upload documentation of the following 6 items:

Your training certificate
Documentation of HIPAA training
Documentation of Trauma-Informed Care training
Current CPR or Basic Life Support certificate
Documentation of Implicit Bias/Cultural Competency training
Documentation of Anatomy and Physiology training

PLEASE CHECK THIS BOX to reveal the File Upload field.

Documentation for Doulaing the Doula*

Upload documentation of the following 2 items:

Your training certificate
Current CPR or Basic Life Support certificate

PLEASE CHECK THIS BOX to reveal the File Upload field.

Documentation for DoulaVersity*

Upload documentation of the following 4 items:

Your training certificate
Documentation of HIPAA training
Documentation of Trauma-Informed Care training
Current CPR or Basic Life Support certificate

PLEASE CHECK THIS BOX to reveal the File Upload field.

Documentation for Doula Trainings International*

Upload documentation of the following 3 items:

Your training certificate
Documentation of HIPAA training
Documentation of Trauma-Informed Care training

PLEASE CHECK THIS BOX to reveal the File Upload field.

Documentation for Gifted Hands International*

Upload your Gifted Hands International training certificate here.

PLEASE CHECK THIS BOX to reveal the File Upload field.

Documentation for ICEA*

Upload documentation of the following 2 items:

Your training certificate
Current CPR or Basic Life Support certificate

PLEASE CHECK THIS BOX to reveal the File Upload field.

Documentation for International Doula Institute*

Upload documentation of the following 3 items:

Your training certificate
Documentation of HIPAA training
Documentation of Trauma-Informed Care training

PLEASE CHECK THIS BOX to reveal the File Upload field.

Documentation for Jamaa Birth Village*

Upload documentation of the following 3 items:

Your training certificate
Documentation of Trauma-Informed Care training
Current CPR or Basic Life Support certificate

PLEASE CHECK THIS BOX to reveal the File Upload field.

Documentation for MMCI*

Upload documentation of the following 2 items:

Your training certificate
Current CPR or Basic Life Support certificate

PLEASE CHECK THIS BOX to reveal the File Upload field.

Documentation for National Black Doula Association*

Upload documentation of your National Black Doula Association certificate here.

PLEASE CHECK THIS BOX to reveal the File Upload field.

Documentation for NDoula Community Alliance*

Upload your NDoula Community Alliance training certificate here.

PLEASE CHECK THIS BOX to reveal the File Upload field.

Documentation for Paradigm Doulas*

Upload your Paradigm Doulas training certificate here.

PLEASE CHECK THIS BOX to reveal the File Upload field.

Documentation for Partum Health*

Upload documentation of the following 2 items:

Your training certificate
Current CPR or Basic Life Support certificate

PLEASE CHECK THIS BOX to reveal the File Upload field.

Documentation for Sista Midwife Productions*

Upload documentation of the following 6 items:

Your training certificate
Documentation of HIPAA training
Documentation of Trauma-Informed Care training
Current CPR or Basic Life Support certificate
Documentation of Implicit Bias/Cultural Competency training

PLEASE CHECK THIS BOX to reveal the File Upload field.

Documentation for SMC Full Circle Doula Training*

Upload documentation of the following 4 items:

Your training certificate
Documentation of HIPAA training
Documentation of Trauma-Informed Care training
Documentation of Implicit Bias/Cultural Competency training

PLEASE CHECK THIS BOX to reveal the File Upload field.

Documentation for Sokana Collective*

Upload documentation of the following 3 items:

Your training certificate
Documentation of HIPAA training
Current CPR or Basic Life Support certificate

PLEASE CHECK THIS BOX to reveal the File Upload field.

Documentation for Sumi's Touch*

Upload documentation of the following 2 items:

Your training certificate
Current CPR or Basic Life Support certificate

PLEASE CHECK THIS BOX to reveal the File Upload field.

Documentation for ToLabor (formerly ALACE)*

Upload documentation of the following 4 items:

Your training certificate
Documentation of HIPAA training
Documentation of Trauma-Informed Care training
Current CPR or Basic Life Support certificate

PLEASE CHECK THIS BOX to reveal the File Upload field.

Documentation for Uzazi Village*

Upload documentation of the following 6 items:

Your training certificate
Documentation of HIPAA training
Documentation of Trauma-Informed Care training
Current CPR or Basic Life Support certificate
Documentation of Implicit Bias/Cultural Competency training
Documentation of Anatomy and Physiology training

PLEASE CHECK THIS BOX to reveal the File Upload field.

Documentation for Virtuously B'earthed*

Upload your Virtuously B'earthed training certificate here.

PLEASE CHECK THIS BOX to reveal the File Upload field.

Documentation for unlisted training organizations*

Upload documentation of the following 7 items:

Your training certificate
A syllabus, topical outline, or other documentation of the training organization's curriculum
Documentation of HIPAA training
Documentation of Trauma-Informed Care training
Current CPR or Basic Life Support certificate
Documentation of Implicit Bias/Cultural Competency training
Documentation of Anatomy and Physiology training

PLEASE CHECK THIS BOX to reveal the File Upload field.

Legacy Pathway Applicants Required Documentation*

Upload documentation of the following 5 items:

Documentation of HIPAA training
Documentation of Trauma-Informed Care training
Current CPR or Basic Life Support certificate
Documentation of Implicit Bias/Cultural Competency training
Documentation of Anatomy and Physiology training

NOTE: If you received training in any of these 5 areas from an approved doula training organization, please upload your training certificate as a form of documentation.

PLEASE CHECK THIS BOX to reveal the File Upload field.

File Upload

Add your required documentation here. Multiple files may be attached.

Drag and drop files here or

Your Professional Doula Work Experiences

List below references who can attest to your perinatal birth experiences.

Remember 3-1-1 for the Training Program Pathway

3 perinatal doula clients listed as references on this form
Births occurring within past 1 year from today
And 1 reference submits an Experience Verification form on your behalf

Remember 5-3-3 for the Legacy Pathway

5 perinatal doula clients listed as references on this form
Births occurring within past 3 years from today
And 3 references submit an Experience Verification form on your behalf

# 1 Legacy Pathway Birth Experience

REMINDER: For Legacy Pathway, the birth date must be within the previous 3 years (36 months) of today's date.

# 1 Training Program Pathway Birth Experience

REMINDER: For Training Pathway, the birth date must be within the previous 1 year (12 months) of today's date.

# 1 Last name of the birth person

# 1 Type of doula support you provided

Select one or more of the following types of support that you provided to this birth person.

Select or enter value

# 1 Hospital/Clinic or Community-Based Doula Org.

If you provided labor and delivery support for this birth person, and the labor and delivery occurred in a hospital or clinic, please provide the hospital or clinic name here.

If you provided doula support for this birth person as part of your work in a community-based doula organization, please provide the doula organization name here.

# 1 City where doula services were provided

# 1 Birth person's email address

#1 Birth person's phone number

Phone

#2 Legacy Pathway Birth Experience

REMINDER: For Legacy Pathway, the birth date must be within the previous 3 years (36 months) of today's date.

# 2 Training Program Pathway Birth Experience

REMINDER: The birth date must be within the previous 1 year (12 months) of today's date.

# 2 Last name of the birth person

# 2 Type of doula support you provided

Select one or more of the following types of support that you provided to this client.

Select or enter value

# 2 Hospital/Clinic or Community-Based Doula Org.

If you provided labor and delivery support for this birth person, and the labor and delivery occurred in a hospital or clinic, please provide the hospital or clinic name here.

If you provided doula support for this birth person as part of your work in a community-based doula organization, please provide the doula organization name here.

# 2 City where doula services were provided

# 2 Birth person's email address

# 2 Birth person's phone number

Phone

#3 Legacy Pathway Birth Experience

REMINDER: For Legacy Pathway, the birth date must be within the previous 3 years (36 months) of today's date.

# 3 Training Program Pathway Birth Experience

REMINDER: The birth date must be within the previous 1 year (12 months) of today's date.

# 3 Last name of the birth person

# 3 Type of doula support you provided

Select one or more of the following types of support that you provided to this client.

Select or enter value

# 3 Hospital/Clinic or Community-Based Doula Org.

If you provided labor and delivery support for this birth person, and the labor and delivery occurred in a hospital or clinic, please provide the hospital or clinic name here.

If you provided doula support for this birth person as part of your work in a community-based doula organization, please provide the doula organization name here.

# 3 City where doula services were provided

# 3 Birth person's email address

# 3 Birth person's phone number

Phone

# 4 Legacy Pathway Birth Experience

REMINDER: For Legacy Pathway, the birth date must be within the previous 3 years (36 months) of today's date.

# 4 Last name of the birth person

# 4 Type of doula support you provided

Select one or more of the following types of support that you provided to this client.

Select or enter value

# 4 Hospital/Clinic or Community-Based Doula Org.

If you provided labor and delivery support for this birth person, and the labor and delivery occurred in a hospital or clinic, please provide the hospital or clinic name here.

If you provided doula support for this birth person as part of your work in a community-based doula organization, please provide the doula organization name here.

# 4 City where doula services were provided

# 4 Birth person's email address

# 4 Birth person's phone number

Phone

#5 Legacy Pathway Birth Experience

REMINDER: For Legacy Pathway, the birth date must be within the previous 3 years (36 months) of today's date.

#5 Last name of the birth person

# 5 Type of doula support you provided

Select one or more of the following types of support that you provided to this client.

Select or enter value

# 5 Hospital/Clinic or Community-Based Doula Org.

If you provided labor and delivery support for this birth person, and the labor and delivery occurred in a hospital or clinic, please provide the hospital or clinic name here.

If you provided doula support for this birth person as part of your work in a community-based doula organization, please provide the doula organization name here.

# 5 City where doula services were provided

# 5 Birth person's email address

# 5 Birth person's phone number

Phone

Assurance & Release

By signing below, I attest to the following:

I have reviewed and understand the Illinois Medicaid-Certification Doula Guide.

Reviewed*

I am committed to the Doula Code of Ethics in the Illinois Medicaid-Certified Doula Guide

Committed *

I attest that all of the information submitted with this application and supportive documents are true and honest.

Documents are true*

NPI number

Please include your NPI number, if you have one.

Applicant's Signature

Feedback

Thank you for completing the Illinois Medicaid-Certified Doula application. This brief survey is designed to collect your feedback about the application experience.

How easy was this application to complete?*

Very Easy

Somewhat Easy

Not Easy

What needs improvement on this application?

Were there any confusing areas?*

Not Confusing

Some Minimally Confusing Questions

Major Confusion

Which part of the application was confusing?

Experience Verification Form

Send your clients this link to the Experience Verification Form.

This form will open in a new tab. You can copy the URL and paste it into an email or text message to your client.

Send me a copy of my responses

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