Name

First Name

Last Name

Phone Number

Estimated Due Date

YYYY

Name and relationship of primary support person (partner, spouse, friend, family member, etc)

Number of children

How many babies are you expecting (or did you deliver)?

Where do you plan to deliver?

Do you qualify for any state assistance (SNAP Benefits, TANF, Day Care assistance)? If you are unsure, follow the link for a list of federal poverty level guidelines. https://aspe.hhs.gov/poverty-guidelines

Are you a two income family?

Yes, my partner and I both work outside of the home.

No, only one of us works outside of the home.

No, I'm a single parent and the sole income earner.

Do you rent the home you live in?

When was the last time you took a vacation? On your last vacation did you spend more than $500?

Do you identify as a member of an "Untapped" community (Black, Indigenous, Latinx, LGBTQAI+, Muslim, working poor, disabled people or people experiencing mental illness)?

What is your annual household income?

Is there anything else you'd like us to know about you or what lead you to seek services?

Untapped Fund Application

North Star Doula Service