Snuggle House Foundation Request Form
tell us about your request
Who is this request for?
Please select...
Myself or my child
A friend of Family Member
I'm a Snuggle House Foundation doula filling out a request for a client I am already planning to work with
First Name
Last Name
Date of Birth
Email
Pronouns
She/Her
He/Him
They/Them
Other
Phone
(numbers only, no dashes)
City
Street Address
State
Zip Code
Previous Snuggle House Foundation Client
Are you currently pregnant?
Yes
No
Is this your first pregnancy?
Yes
No
What Service Are You Interested In? (select all that apply)
Birthworker Training
Birth Services
What Birth Services are you interested in?
Birth (Doula) Support
Postpartum Support
Therapy & Wellness
What Therapy & Wellness services are you interested in?
Prenatal Yoga
Massage & Acupuncture
Perinatal & Family Therapy
Body Work Assessment
Classes & Workshops
What Classes are you interested in?
Childbirth Education
Family Centering Groups
Helping Families Navigate Parenthood
Informed Consent Class
Undecided
Pregnancy Information
Estimated due date
Where do you plan to give birth?
Please select...
Abbott Northwestern (Mother Baby Center)
Buffalo Hospital
Fairview Ridges (Burnsville)
Fairview Riverside (U of M)
Fairview Southdale (Edina)
Health Foundations Birth Center
Home Birth
Lakeview Hospital (Stillwater)
Mankato Hospital
Maple Grove Hospital
Mercy Hospital (Mother Baby Center)
Methodist (St. Louis Park)
Minnesota Birth Center-MPLS
Minnesota Birth Center-St. Paul
Northfield
North Memorial (Robbinsdale)
Regions (St. Paul)
Ridgeview Medical Center (Waconia)
River Valley Birth Center
Roots Community Birth Center
Saint Francis (Shakopee)
Saint Johns (Maplewood)
United (Mother Baby Center)
Willow Birth Center
Woodwinds (Woodbury)
Other
Undecided
Clinic Name
This is where you are currently being seen for this pregnancy.
Healthcare Provider
Have you worked with a Snuggle House Foundation Birthworker?
Yes
No
Enter name of Snuggle House Birthworker
Insurance & payment Information
At Snuggle House Foundation we offer Sliding Scale tier options to ensure accessibility and access to all families regardless of financial circumstances.
Learn more about our sliding scale rates
here
.
Insurance Information
Please select...
Medical Assistance (state-sponsored plans)
Private Insurance (through employer or family member)
Not Currently Insured
Who Are You Insured Through?
Please select...
State-Sponsored Blue Plus
State-Sponsored Health Partners
State-Sponsored South Country Health Alliance
State-Sponsored Ucare
Straight MA
State-Sponsored United Health Care
PrimeWest
Which Tier Best Represents Your Family?
Please select...
Tier 1 - Combined Family Income $78,000+
Tier 2 - Combined Family Income Between $45,000 - $77,999
Tier 3 - Combined Family Income Below $44,999
Insurance ID Number
Insurance Group Number
Upload Insurance card
Please upload the FRONT of insurance Card
Please upload the BACK of your Insurance Card
Demographic Information
This section is used to collect data around our impact and the services we offer. We acknowledge the history of demogrpahic data collection and the inhert racism it has held in our country. Snuggle House Foundation will NEVER use this information to be discriminatory, harmful, or prejudice.
The below demogrpahic information is solely used to empower our community with accurate, current, data that reflects representation of our community impact.
Ethnicity
Please select...
African Decent
African American
Afghan
Asian/Pacific Islander
Hispanic/Latina
Caucasian
Native American
Somali
Hmong
Other/Mixed
Prefer Not to Say
Primary Language
Do You Speak English?
Yes
No
Requires an Interpreter
Yes, I would like to sign up for Snuggle House Foundation News and Updates
Contact Information