Use this form if you are a client requesting services for yourself. If you are a referring agency, making a request for a client OR helping a client complete this request, please use the REQUEST FOR SOMEONE ELSE form instead.
We receive a high volume of requests. Taking the time to read the information on the request form fully to make sure you are 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.
For most requests, we must communicate with the client before moving forward in the process. Please watch for follow-up communication from Everyday Miracles.
Note: the name listed on this request must exactly match the name listed on your insurance card/plan, or we will be unable to validate coverage. We are not able to process requests without valid insurance information.
* = Required field
Our doulas take a limited number of clients and placement may be challenging for clients very close to their birthing times. Requests for clients who are 32 weeks pregnant and beyond, or who require a doula that speaks a language other than English, should be pre-approved by the doula coordinator before submitting the request form. Please contact email@example.com
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.