Jersey Doula Network Alliance
Client Intake & Enrollment
🌐 www.jerseydna.com 📄 Billing Policy 🔒 Privacy Policy
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Client Intake Form

Complete all steps — takes about 6 minutes

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About You
Services
Coverage
Sign
About You
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Location
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Service Needed * — select all that apply
Please select at least one service
Coverage *
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Insurance Coverage

Medicaid, Horizon, Aetna & more

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Self Pay

Flexible packages & payment plans

Please select a coverage type
Consent & Authorization *
HIPAA & Privacy Notice: Jersey Doula Network Alliance is committed to protecting your health information. Your personal and health data will be used only to provide doula services and coordinate care. We will not sell or share your information with third parties without your written consent, except as required by law.
Consent to Contact: By checking below, you agree that Jersey Doula Network Alliance may contact you by phone, email, and/or text message regarding your intake, appointments, and care coordination. Standard message and data rates may apply.
Service Agreement: I understand that doula services provided by Jersey Doula Network Alliance are non-medical support services. My doula is not a licensed medical provider and will not replace the care of my OB, midwife, or other healthcare providers.
Billing Policy: I have read and understand the Jersey Doula Network Alliance Billing Policy, including that insurance coverage is not guaranteed, that I may be responsible for self-pay fees, and that payment is due per the terms outlined at the time of service.
Please check all four consent boxes to continue
Electronic Signature *
By typing your full name below, you are signing this form electronically. Your electronic signature is the legal equivalent of your handwritten signature.
Required