A Guided Journey

A Guided Journey Referral Form
Which option below describes this referral?
To participate in A Guided Journey you must:

· Be pregnant or up to 90 days post-partum
· Meet income requirements (You qualify if you are eligible for Medicaid or WIC.)
· Live in Mecklenburg County
Client Basic Information
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Due Date/Delivery Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Is this your first pregnancy?
Are you interested in postpartum doula services?
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Client's Emergency Contact Information
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Client
Language Preference
Race
Ethnicity
Please provide any additional comments or helpful information below.
Should be Empty:

A Guided Journey Referral Form