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(651)793-3803
      Ext.3022
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(651)793-3809

Doulas.Net
579 Wells Street
St Paul, Minnesota
55130
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Assessing Risk Factors during Pregnancy


Also available: Lactation Counseling Referral
Postpartum Doula Referral

The Community Doulas at AIFC provide doula services in an effort to reduce health disparities in communities of color; American Indian, Latino, Asian, African Immigrant, and African American.

Patient referred for doula services must have a minimum of 3 of the following risk factors. Please fax or send this form with the referral form.

Part Two Doula Referral, Risk Assessment :

*required

Client Name :

* (First Name) * ( Last Name )


Check all risk factors known to be present during pregnancy :


Social :






homeless or in temporary housing
domestic violence or sexual assault victim
child protective services involved current
social isolation / lack of family or social support
low income eligible for MA
non-English speaking (or deaf)


Medical :
diseases that effect pregnancy (diabetes, hypertension)
previous preterm birth
miscarriage
under age 16 or over age 35
HIV / STD infections
prenatal care initiated after first trimester
diseases or infections
poor weight gain
multiple pregnancy (twins, triplets…)
pregnancy or third child expected within 3 ˝ years
previous infant death (birth up to one year old)


Mental Health :


history of diagnosis or treatment of mental health problems
reported or observed signs of depression, anxiety, or disordered thinking


Behavioral Information :
Tobacco use (Type/Frequency) :
alcohol use (Type/Frequency) :
drug use (Type/Frequency) :


Other issues that
effect this pregnancy or
mother’s health and safety : :
Need for resources / information :
If you prefer, attach file here :

You may also :
Download this form as a .pdf file

You may also :
Call in to 651-793-3803 / or fax to 651-793-3809
Or Mail : Doula Program / 579 Wells St. / St. Paul, MN 55130