Referral form
Provider Referral Form for Nueva Vida Doula in Humboldt County
A short, fillable referral form for obstetric providers and OB patients connecting families with Nueva Vida Doula for pregnancy, birth, postpartum, partner, and family support.
Downloadable form
A shorter referral form for provider offices and OB patients.
To keep referrals simple, this page uses one streamlined referral form only.
Nueva Vida Doula Referral Form
Use this fillable PDF when referring a family to Nueva Vida for non-medical pregnancy, birth, postpartum, partner, or family support.
What the form asks for
The form includes patient contact information, EDD or LMP, preferred contact method, referring provider details, optional referral reasons, and optional notes.
Submit the form
Send the completed referral form to Nueva Vida.
The completed referral form may be sent by secure email, fax, or mail. For urgent or short-notice support, contact Nueva Vida directly in addition to sending the form.
How to use the form
A simple referral flow.
The referral form is intentionally short so providers and OB patients can complete it quickly without unnecessary paperwork.
Suggested workflow
Download the form
Use the fillable PDF referral form when a provider or OB patient wants to connect with Nueva Vida.
Complete patient information
Add the patient’s name, date of birth, EDD or LMP, contact information, and preferred contact method.
Add provider details
Provider name, clinic, phone, fax, and date of referral can be added when an office is making the referral.
Select optional reasons
Check any helpful referral reasons, such as first-time parent, birth trauma history, anxiety, limited support, or postpartum interest.
Submit the form
Send the completed form by secure email, fax, or mail. Call Nueva Vida directly for urgent or short-notice support.
Nueva Vida follows up
Our team contacts the family to explain consultation, coverage next steps, and doula support options.
Provider cheat sheet
Quick facts about Nueva Vida Doula.
Use this section when your office needs a fast summary of who we support, what we provide, and how families can get started.
Who we are
Nueva Vida Doula is a team-based doula organization in Eureka, California, supporting families since 2015.
Service area
We support families in Eureka, Arcata, McKinleyville, Fortuna, and throughout Humboldt County.
Services
Pregnancy support, birth support, postpartum support, partner support, family education, and care navigation.
Team model
Families are supported by a coordinated team, helping Nueva Vida respond more reliably than a solo doula model.
Coverage
Many families may qualify for Partnership HealthPlan or Medi-Cal doula benefits. Eligibility and plan details apply.
Spanish support
Se habla español. Spanish-speaking support is available when scheduling and team availability allow.
Clinical boundary
Doula support is non-medical support.
Nueva Vida works alongside a family’s medical care team. Our doulas provide emotional, educational, physical, and practical support, but we do not replace clinical care.
- We do not diagnose or treat medical conditions.
- We do not provide medical advice or replace provider instructions.
- We do not perform clinical tasks.
- We encourage families to stay connected with their physicians, midwives, nurses, and licensed care providers.
Related provider pages
Provider support pages.
These pages help providers refer families, understand the Nueva Vida process, and connect families with the right next step.
Provider Center
Start here for an overview of Nueva Vida’s provider referral pathway and support model.
Refer a Patient
See referral options, short-notice support guidance, what to include, and what happens after referral.
Community Partners
Explore local pregnancy, birth, postpartum, feeding, wellness, and family support resources.
Provider FAQ
Questions about the referral form.
Which form should a provider use?
Use the Nueva Vida Doula Referral Form. This page points to one short referral form only.
Can OB patients complete the form themselves?
Yes. The form is designed for obstetric providers and/or OB patients to complete.
Can families contact Nueva Vida without a formal referral?
Yes. Families may self-refer by scheduling a free consultation. The referral form is available when a provider office or patient wants a documented referral path.
Can providers fax the referral form?
Yes. The completed referral form may be faxed to (707) 607-1033.
Can the completed form be emailed?
Yes. The completed form may be sent by secure email to info@NuevaVidaDoula.com. Please use your office’s privacy workflow when sending patient information.
Does a referral guarantee coverage?
No. Many families may qualify for doula support through Partnership HealthPlan or Medi-Cal, but eligibility and plan details apply. Coverage is not guaranteed.
Do doulas provide medical care?
No. Nueva Vida provides non-medical doula support. We do not diagnose, treat, provide medical advice, perform clinical tasks, or replace care from licensed medical providers.
Can providers request short-notice support?
Yes. Providers may contact Nueva Vida when a family needs support quickly, including near labor or birth. Availability, location, family consent, eligibility, and service fit still apply.
Do you support Spanish-speaking families?
Yes. Se habla español. Spanish-speaking support is available through the Nueva Vida team when scheduling and team availability allow.
Ready to send a referral?
Download the form or send the family to schedule.
Providers and OB patients can use the referral form, submit by secure email, fax, or mail, or schedule a free consultation directly.