Birth Support Request Form Name First Name Last Name Who is this request for? Myself or my child A friend or Family Member I'm a Snuggle House Foundation doula filling out a request for a client I am already planning to work with. Phone * (###) ### #### Are you currently Pregnant * Yes No Is this your first pregnancy? Yes No Estimated Due Date * MM DD YYYY Insurance Type * State-Sponsored Blue Plus State-Sponsored Health Partners State-Sponsored South Country Health Alliance State-Sponsored UCare Straight MA State-Sponsored United Health Care PrimeWest PMCI/MHCP Number * 8 digit Number (Please include all 8 digits, even if some are zeros). **PrimeWest Insurance Type please put N/A** Insurance ID Number * Information About the Person Who Will Receive Services: Pronouns * She/Her He/Him They/Them Other Birthdate * This is your date of birth, not your due date or Childs date of birth MM DD YYYY Where you born outside the United States? Yes No Are you a previous Snuggle House Foundation client? Yes No Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Ethnicity * African Decent African American Afghan Asian/Pacific Islander Hispanic/Latina Caucasian Native American Somali Hmong Other/Mixed Prefer Not to Say Primary Language * Do You Speak English? * Yes No If you are ALREADY working with a Birth Worker from Snuggle House Foundation, please enter their name. Birth Location * Abbott Northwestern (Mother Baby Center) Buffalo Hospital Fairview Ridges (Burnsville) Fairview Riverside (U of M) Fairview Southdale (Edina) Health Foundations Birth Center Home Birth Lakeview Hospital (Stillwater) Maple Grove Hospital Minnesota Birth Center - MPLS Minnesota Birth Center - St. Paul Mercy Hospital (Mother Baby Center) Methodist (Saint Louis Park) North Memorial (Robbinsdale) Northfield Regions (St. Paul) Roots Community Birth Center Saint Francis (Shakopee) Saint John's (Maplewood) United (Mother Baby Center) Willow Birth Center Woodwinds (woodbury) Other Undecided Clinic Health Care Provider Covid Preferance I would like to request a doula who is vaccinated for Covid-19 I am open to a doula regardless of vaccination status Comments or other things to know? Thank you! Your request has been submitted and a team member will be reaching out to your shortly!
