Fee Assistance Application

In completing this application, you understand that Marissa Peterson, Doula, does NOT (in most cases) provide full fee assistance and clients are often asked to pay something toward the desired services. By applying for assistance, you will most likely be eligible for a reduced rate. All information in this application must be accurate. If at any time it is discovered inaccurate information has been provided, the doula-client relationship is immediately ended, and all monies collected will be non-refundable.

Name *
Name
Date of Birth *
Date of Birth
Phone *
Phone
Partner's Name
Partner's Name
(If applicable)
Partner's DOB
Partner's DOB
(If applicable)
Please be aware that this includes the pre-tax income of all persons over the age of 18 in your home.