Application to the Doula Access Fund
Details of the person / organisation making the referral
Your Name
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Position
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Organisation
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Email
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Phone
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Details of the service user
Name of the person you are referring
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Email of the person you are referring
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Contact number of the person you are referring
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Address of the person you are referring including post code
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Please confirm the service user is experiencing financial difficulty*
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Yes
*Proof of receipt of benefits or no recourse to public funds will be required. (You can upload a file below or email proof to accessfund@doula.org.uk)
and fills one or more of the following criteria (please tick all that apply)
Lone parent
Black or Asian
Mental health diagnosis
Fleeing domestic violence
Homeless or in temporary housing
In the Social Work system
Registered disability
Survivor of trafficking or abuse
Estimated due date
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Which service are you applying for?
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Birth Doula Support
Postnatal Doula Support
If an available local doula cannot be found would the client consider virtual support?
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Yes
No
Location (nearest Town or City)
Place of birth (birth support) or client's post code for postnatal support
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Any additional information you would like to add
Supporting evidence (proof of benefits)
Drop a file here or click to upload
Choose File
Maximum file size: 67.11MB
Admin notes (hidden from front end)
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