DOULA PROVIDER APPLICATION Legal Name * First Name Last Name Business Name / DBA Date of Birth * MM DD YYYY Social Security Number * Business Email * Business Phone * Country (###) ### #### Business Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Please describe your race, ethnicity and/or cultural identity. * For pairing purposes only - clients may request a culturally concordant doula. Languages (other than English) Services Offered * Please check all that apply. prenatal labor postpartum childbirth education patient navigation breastfeeding other Experience Level * Key: apprentice = trained as a doula, but minimal hands-on experience OR some hands-on experience but not formally trained as a doula. professional = trained as a doula AND significant hands-on experience as a doula mentor = professional doula willing and able to train other doulas apprentice professional mentor When and where (name of agency, doula trainer, program, etc.) did you receive your formal doula training? * If you are not a formally trained doula, please state that. Where do you work as a doula presently? * Select all that apply. Hospital-based program Small doula practice Self-employed/freelance I do not work as a doula currently How many clients per month are you interested in taking? * 1 2 3 4 5+ Are you already enrolled as a MassHealth doula provider? * Yes No If yes, please include your NPI and PIDSL. If no, please select one of the following. MassHealth enrollment is required for all doula providers under Doulas of the Diaspora. It is required that you enroll as a MassHealth provider prior to beginning employment with Doulas of the Diaspora. If you are unable or unwilling to enroll as a provider on your own, you may agree to a deduction of a $100.00 enrollment fee for admin to complete this process for you. This enrollment fee is waived for all graduates of Doulas of the Diaspora doula training. I will complete the enrollment on my own. I would like admin to enroll me on my behalf. What are you seeking to become a Diaspora doula? * In what ways will you contribute to the culture of Doulas of the Diaspora? * What are your personal and professional goals? * Please list one personal reference. * Please list one professional reference. * Thank you for submitting your application! You will receive a copy of your application and next steps via your email address in 24-48 hours.
