Midwifery or Doula Client Intake Form

Midwifery or Doula Client Intake Form
Currently, our Emergence Fund is only open to pregnant Indigenous people in the United States or Canada.

To qualify for funding, the client must have proof of being Indigenous. Examples are:
- CIB-Tribal ID
- Per capita payment check stub
- Letter/prescription from IHS with your name
- Enrollment letter OR descendant letter
- Drivers License/I.D. required
What we will fund:
- Midwifery services- Must be an CNM or LM with a valid licence
- Doula services
- Breastfeeding/chest feeding support
- Supplies for your growing family
- Placenta encapsulation, herbal support, traditional medicine
We will contact you within 48-72 hours after you submit an application.
2nd email sent

accepted emaildeclined emailover capacity email
Today's Date*

MonthDayYear
Date
What is your name?*

First NameLast Name
What is your date of birth?*

MonthDayYear
Date
Estimate birth due date?*

MonthDayYear
Date
What is your gender identity (male, female, non-binary, etc.)?*

MaleFemaleNon-BinaryPrefer Not To Say
Phone Number*
Please enter a valid phone number.
Valid Mailing Address (if we need to send you supplies, or something cool!)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Best way to contact you?*

Phone call / llamadaEmail / correo electrónicoText / mensaje de texto
If we call, is it safe to leave a voicemail?*

YesNo
Do you have Medicaid from your state or private insurance?*
We can provide you with resources that may be able to help you.
What Indigenous community or tribe do you identify or belong to?*
Please upload a picture of your Driver license/I.D., CIB, letter of descent, or any other proof of belonging to an Indigenous community.*

Take a picture of your proof and attach it here!
Cancelof
Which of these are resources do you need?*

Midwifery care - out of hospital birthDoulaOther
if other selected, please specify what is needed
example: breast pump, traditional ceremonies supplies .......
How did you hear about the IWR Emergence Fund?*
We want to know how we can reach more people!
Would you be willing to share your journey in our Emergence Fund newsletter? (Don't worry, we won't be all cheap if you say no. If you do decide you would like to share, we would send you something cool. I promise.)*

YesNoMaybe
Do you have questions or concerns you want to share with us?
Signature for agreement for terms and conditions*

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Program ID
Service ID
Quantity
applicant accepted for funds

yesnoBudget has been meet for month
notes or relevant information
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