* Full Name

* Email

* Phone

* Age Under 20 years
20-29 years
30-39 years
40-49 years
50-59 years
60+ years

* Best time to call you (please include your time zone)

How did you hear about us? (Please check all that apply) Family/Friend
E-mail
Internet
Local Magazine/Newspaper
DONA Website
Other

* Are you pregnant? Yes
No

If expecting, how many weeks pregnant are you?

* Which of the following options best describes your situation? Married, partner present
Married, partner not present
Divorced
Unmarried, partner present
Unmarried, partner not present

* Please state the top 3 things that you hope to gain from your birth experience:

* What are the top 3 things that you are looking for in your birth doula?

Do you wish to share any other informatiion with your potential doula?

* Are you comfortable having a student doula attend our prenatal meetings and your birth? Yes
No
Maybe