Use this form if you are a referring agency requesting services for your patient/client.

We receive a high volume of requests. Taking the time to read the information on the request form fully to make sure the client is eligible for the services being requested and including the most accurate information is the easiest way to ensure we can process requests as quickly as possible. If you have any questions, we ask that you contact us BEFORE submitting the request form. 

Due to the volume of requests, we do not automatically send a request confirmation to the referring organization. However, if you would like to follow up on a request, please contact us via email.

Note: the name listed on this request must exactly match  the name listed on the client's insurance card/plan, or we will be unable to validate coverage. We are not able to process requests without valid insurance information.

* = Required field

I would like to request: *
Please note the accepted insurance types listed below for each type of request. Make your request ONLY if you have that type of insurance. We are no longer doula requests for those birthing in 2016. Doula availability for those 32 weeks and beyond is very limited.
Request Program Eligibility *
I understand that Everyday Miracles has specific eligibility requirements for different types of requests/referrals. I understand that my request referral cannot be processed without valid insurance information.
Car Seat Requests *
If you are requesting for a child (who is already born), we MUST HAVE the mother's name and DOB in order to process the request. You may enter this information in the comments section of this form.
Doula Requests *
Doula requests for clients 32 weeks or beyond should be made only with prior conversation/approval with the doula coordinator. YOU MUST contact the doula coordinator if you are requesting a doula and you are 32 weeks pregnant or beyond. This should be done prior to submission, or your request will not be processed:
Client's Name *
Client's Name
If the child is already born, the child is the client. If you're the parent waiting for your baby to arrive, you are the client.
Estimated Due Date
Estimated Due Date
Estimated date you expect your baby to be born. This information is required if the referral is for an expectant mother.
Phone Number *
Phone Number
Address *
This eight-digit number helps facilitate a swifter verification of Medicaid coverage. It can be found on their Minnesota Medical Assistance card.
Insurance Type *
Please enter a valid insurance number, your referral will NOT be processed without one.
Date of Birth *
Date of Birth
We need this information to verify program eligibility. If you are an expectant mom requesting a seat for your unborn child, please enter your DOB. If you are requesting a car seat for a child, please enter the child's DOB.
This is for car seat requests/referrals.
This information is required for all doula referrals.
Where are you being treated? Who are you seeing?
Does the client speak English? *
Please note. We work hard and are honored to serve every client. However, we have limited staff and resources. If the client does not speak English, additional time may be needed to process the request. Please also be sure to include your direct contact information in the event we need additional assistance facilitating this request.
If you are making a DOULA request, please share any information that you feel would assist us in pairing you with a doula. You may include birth preferences, faith practices/traditions that may play a role in your birth, specific anxieties, personalities you feel most comfortable with or anything else you would like us to know when considering your doula match. If you are making a CAR SEAT request for a child who is already born, you must include the mother's name and date of birth (including year) in this section.
Your Information
Referral source contact information.
Referrer's Name *
Referrer's Name
Phone Number *
Phone Number


We do our very best to fulfill every request. However, please contact our Doula Coordinator BEFORE submitting your request if it is for someone who is 32 weeks pregnant or beyond. Doula availability is very limited in those cases.


We work hard to get car seats to clients as soon as possible. Because of the high volume of requests, car seat deliveries may take up to three weeks after initial referral and deliveries are scheduled according to estimated due date. 


If you are requesting a breast pump, please request a prescription from your provider.  You can request that your provider fax the prescription to us at to our office at 612-353-6437 or give the prescription to us upon delivery of your breast pump. Breast pumps can be delivered or picked up.


If you have any questions about doula request/referral, please contact Melissa Gutierrez Nelson. If you have questions about your car seat request, contact  Abby Peters.  If you have questions about breast pump requests, please email Debby Prudhomme.