Name:  

Address: 

Phone Numbers:

     Home Phone: 

     Cell Phone: 

     Work Phone: 

Email: 

Name, Dates & Location of Doula Training Workshop: 

Are You Certified?  Yes No        

If working towards certification, when do you anticipate completion?: 

What areas are you willing to work in?:

     Marin

     San Francisco

     San Mateo

     Santa Clara

     Alameda/East Bay

     Contra Costa

Are there areas/hospitals you prefer to work in?  :

Are there areas/hospitals you prefer NOT to work in?  :

Do you speak any languages other than English? If so, which? 

List number of months or number of births you plan to work within the BABA mentor doula program?  

Do you agree to: (Please mark Y or N)

  1) BABA Standards of Practice? Yes No

 2) Being a current member in good standing of BABA? Yes No

 3) Complete and return BABA evaluation forms within a timely manner (2 weeks)? Yes No

  Within reasonable limits, do you agree to:

 4) Contact your doula-in-training within 48 hours of her initial call? Yes No

 5) Attempt to provide an interview where you include the option of being accompanied with a doula in training? Yes No

 6) If possible, provide a prenatal and postpartum visit accompanied by your doula in training? Yes No

 7) Provide continuing support to the new doula you mentor? Yes No

How did you hear about BABA?