Bini Birth Doula Registry Client Intake Fiorm

Doula Registry Client Intake Form

Thank you for your inquiry about Bini Doula Services.
We pride ourselves on excellence of service by providing you with a personal selection of birth and/or postpartum doulas.

The price for using our services is $50.00. (Fee waived for couples who participate in our childbirth education course*)
*Baby care & Comfort Measures not included

What is included:

An individual assessment of your needs by Ana Paula Markel
Privacy of your information and requests
Optimum match probability. We will only match you with doulas inside your budget, who are AVAILABLE, and who match your personal preferences
Guarantee excellence of back-up doulas
A selection of professional and experienced doulas
Assurance that our newest doulas are mentored by our founder along with other experienced doulas
Option of personal meeting with Ana Paula to discuss your needs ( 30 min )
Access to Bini's lending library

We would love to have you as a client. We are very passionate and committed to making this experience fulfilling for all involved.

Sincerely,
Ana Paula Markel & The Bini Birth Team

Name *

First

Last

Email *

Phone Number *

What kind of doula would you like to be matched with? *

Birth Doula Postpartum Doula Both Other

Estimated Due Date *

Place of Birth *

Which hospital or center, if not at home?

Care Provider Name? *

OB/GYN or Midwife

What is Your Budget? *

Experienced, certified birth doulas services range from $1000-$3500.
Doulas charge according to experience level.
The average price for Postpartum Doulas is $30-$40/hour.
The more specific you can be, the more helpful it will be for us to find a doula who is within your budget. Please keep in mind doulas and clients can discuss payment plans, discounts, etc.

Bini is completely committed to finding a doula for every woman regardless of budget.
If you would like to hire a doula who has taken the training and is not yet certified, let us know.

What Are You Looking for in a Doula? *

Characteristics, philosophy, experience?

In What Area Do You Live? *

e.g. Encino, East Hollywood, Westside

If Looking for Postpartum Services... *

1.) What hours or days vs. nights are you anticipating to have the doula with you?
2.) Do you plan on breastfeeding? This helps us find you someone with lactation knowledge.

Anything Else You Would Like to Share? *

How Did You Hear About the Bini Doula Registry? *

Did You Take a Childbirth Class at Bini? *

If so, please specify a date!

Bini Registry Referral Fee : Please Indicate Your Payment Method of Choice *

The fee of $50.00 can be paid through PayPal (binibirth@aol.com) or if you'd like to pay by credit card, please indicate and we will contact you to get that information over the phone.

Once the referral fee is received, please allow 24 hours to hear back from us with an introductory email and start the matching process.
We strive to find the very best doula for you. Thank you!

*Please Note: The $50 referral fee is non-refundable and covers the time we put into checking the doulas availability and correspondence. This applies whether you hire a doula from our registry or not. This fee is waived to couples who take our childbirth education classes.*

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