New Jersey Doula Network Alliance
Client Intake & Enrollment Form
🌐 www.jerseydna.com 📞 732-844-9179
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Info
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Services
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Payment
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Schedule
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Consent
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Done
Step 1 of 4 — Client Information
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Client Information

Tell us a little about yourself

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Services Requested

Select all that apply to your needs

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Payment & Coverage

How would you like to pay for services?

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Insurance Coverage

Medicaid, Horizon, Aetna & more

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Self Pay

Flexible packages & payment plans

ℹ️ Please have your insurance card ready. We'll verify your benefits within 1 business day.
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Pay with Zelle

Send your deposit directly via Zelle — fast, free, and secure.

Zelle to

JerseyDoulaNetwork

NJ Doula Network Alliance

Zelle QR Code

Scan to pay via Zelle · Include your full name in the memo

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Schedule Your Appointment

Pick a time that works best for you

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Consent & Authorization

Please review and sign below

HIPAA & Privacy Notice: New 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 New 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 NJ 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.