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Provider Referral Form for OB/Midwife/Behavioral Health Staff
Please use our
Sliding Scale
form if you are filling this out for yourself.
Sliding Scale Doulas
Client Name
Estimated Due Date (EDD):
Client Email
Client Phone
Client Preferred Pronouns:
She/Her
He/Him
They/Them
Other:
Language (if no English)
Tucson or Phoenix Area:
Choose an option
Planned birth location (name of hospital/birth center)
Provider (midwife/OB/caseworker) Name
Provider Email
Pertinent client info
Client on AHCCS and meets one of the following:
Will otherwise be alone in labor
Will be under 18 years of age at delivery
Intellectual or developmental disabilities
History of trauma or substance abuse
Currently homeless
Currently incarcerated
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