Abortion Doula Support Request Form

Birthworkers of Color Abortion Doula Support Request Form

Your information will be kept private -- we will never share, sell or send your information to anyone outside of our organization. Once we hear from you, we will work to pair you with doula who can provide you with support. We kindly request at least 48-72 hours to process requests for services. If you are needing last minute assistance, please still reach out and we’ll see what we can do. Please read this form carefully and fill out each question to the best of your ability.
Name*

First NameLast Name
What are your pronouns?
E-mail
Phone Number*

Area CodePhone Number
Preferred way to contact*

Phone - ok to leave voicemailPhone - do not leave voicemailEmailTextOther
Other Communication
Where are you located?*

Street Address

Street Address Line 2

CityState / Province

Zip Code or City
Date of Last Menstrual Period

MonthDayYear
What is your age?*

Under 1818-2526-3334-3940+
What race/ethnicity best describes you?*

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderLatino or HispanicWhiteI prefer not to answerOther
Other Race/Ethnicity
How did you learn about our services?

Clinic ReferralDoula ReferralWeb Search (Google)Social Media PostWord of Mouth, Referred by a friendOther
Procedure Information
Do you have an appointment scheduled?

YesNo
What is the date of your appointment?

MonthDayYear
Date
Do you need help finding an abortion provider?

YesNo
Do you need abortion healthcare due to medical reasons or pregnancy loss?

YesNoNot Sure
When do you need doula support? (select all that apply)

Before Abortion Procedure (EX: education, planning, support finding provider, etc)During Abortion Procedure (EX: comfort measures, emotional support, etc)After Abortion Procedure (EX: bodywork, postpartum healing, emotional processing, etc)
Do you have health insurance?

MediCalMedicaidPrivate Health PlanNo insurance
Are you open to using your insurance to access abortion services?

YesNoI am not sure
Doula Preferences

Doula support is based on availability so we will do our very best to match you with a doula that meets your unique needs. All of BWOCC doulas are trained in reproductive justice framework and provide care through a trauma-informed, culturally competent lens.
Do you need doula support in language other than English?

YesNo
Please select the type(s) of support you are seeking? (select all that apply)

Virtual OnlyIn-Person OnlyBoth In-Person and VirtualNot Sure
Please share your language preferences here
What kind of doula are you looking for? (speaks a specific language, cultural, spiritual, or religions needs, experience supporting people with disabilities, LGBTQIA+ friendly, etc)
Is there anything else you would like to share with us? Are there any things you'd like us to know about your needs?
Once you submit this form, we will contact you within 48-72 hours to confirm your information and connect you with doula support.

Thank you!
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Birthworkers of Color Abortion Doula Support Request Form

Procedure Information

Doula Preferences