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
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.