Client Code:CDP615

CDP Data Collection Form

Priority Medicaid Populations (check all that apply):
  • Medically high risk
  • Limited/No family support

Date of Referral: 07/07/2021

Doula: Ellen Tappon

Meet and Greet Date: 07/13/2021

Method: Phone

Date of 1st Prenatal: 08/23/2021

1st Prenatal Attended By: Client, Doula

Location of 1st Prenatal: Avry Park

Time: 2

Notes:

Discussed general and pregnancy physical, mental and oral health, Past pregnancies, births and postpartum experiences, relationship with provider, past/current experiences that might impact birth, Breastfeeding, support needs, Healthy Families referral, Pollywog info. Sent info on COVID vaccine in pregnancy, diabetes in pregnancy, C-section, Big Babies, Physical therapists and chiropractors for pregnancy that take IHN, WIC, Breastfeeding, advanced maternal age,

Total Prenatal Hours With Client: 2

Date Created: November 3, 2021


Invoice Form (Credentialed Doulas)

Invoice Date: 11/03/2021

Check All Services Provided:
  • Prenatal Visit 1


CDP Letter of Agreement

Client signature:

Date signed: 11/03/2021