Community Birth Companion

Birth Companion Project

A doula is a trained, non-medical support person who provides emotional, physical, informational and advocacy to a pregnant mother during the pregnancy, labor and postpartum period. Continuous labor support by doulas have been proven to reduce cesarean sections, increase breastfeeding rates and better birthing outcomes. Our Birth Companions, are Perinatal Health Professionals who are trained to provide detailed information about pregnancy, childbirth, and breastfeeding.

Our program serves mothers who: Live in St. Landry, Lafayette, East/West Baton Rouge, North Iberville, or Pointe Coupee Parish. Currently receive Medicaid, SNAP, or WIC.

Client Referral Form: Birth Companion Project

Date of referral

Our Doula Program includes 4 in home prenatal visits, labor support, 2 postpartum visits, monthly breastfeeding support group, virtual and in-person childbirth education classes. Do you agree to be in this program?

YES
NO

Client Full Name

Phone number (is it okay to text this number?)

Email address

Address

Parish

Date of Birth

Estimated Due Date

Total number of pregnancies (including miscarriages)

Name of Health Insurance/Medicaid

Current Doctor/Delivering Hospital

Race* We use this to evaluate our program in relation to birth outcomes and disparities.

Number of previous c-sections:

Referrer's Name/Organization

Referrer phone number

Referrer email address

Client Approval* Please advise the client you are making this request on their behalf. They should expect additional communication from Community Birth Companion and respond promptly.

I understand

Additional Notes