Provider Referral Form

Refer your patients to Doula Lab's doulas, perinatal health workers, and IBCLC lactation specialists serving Southern Illinois and the St. Louis Metro area.

(618) 255-1234 [email protected] Client Self-Referral Form

For urgent or emergent referrals, please call us directly at (618) 255-1234 in addition to submitting this form.

First Name *

Last Name *

Credentials

Title / Role

Organization / Practice / Hospital *

Provider Type

Phone *

Email *

Fax

Preferred Contact Method

Practice Address

City

State

ZIP

First Name *

Last Name *

Date of Birth

Phone

County

Home Address

City

State

ZIP

Primary Language

Interpreter / language services needed

Estimated Due Date

Gestational Age

Gravida

Para

Pregnancy Risk Level

Clinical Notes / Relevant Medical History

Reason for Referral *

Services Requested (select all that apply)

Urgency Level

Preferred Start Date

Patient Consent: I have obtained verbal or written consent from the patient to share their information with Doula Lab for the purpose of care coordination and doula/PHW services.HIPAA Authorization: A HIPAA authorization or release of information is on file at my organization, or I am submitting this referral under a treatment, payment, or operations (TPO) exception.Provider Attestation *: I attest that the information provided in this referral is accurate and complete to the best of my knowledge, and that I am authorized to make this referral on behalf of my organization. I understand that Doula Lab will use this information solely for care coordination purposes.

* Required fields. All information is transmitted securely and kept confidential.

Urgent Referrals

(618) 255-1234

Referral Email

[email protected]

Response Time

1–2 business days