Apply for Support | Utah Doula Access Project

1

Your contact information

First name

Last name

Email address

Phone number

City / community

Estimated due date optional

2

About your household

Household size including children

Annual household income before taxes

Employment status

3

Insurance & benefits

Insurance that may cover doula services select all that apply

Medicaid / Utah Medicaid

Utah Medicaid doula benefit active April 2026

PEHP — Public Employees' Benefit and Insurance Program

Utah state employees — verify current coverage at pehp.org

Carrot Fertility

Employer benefit covering birth and postpartum doula services

Cigna

Reimbursement varies by plan — verify your specific benefit

Blue Cross Blue Shield

Reimbursement varies by plan — verify your specific benefit

Other insurance

No insurance / uninsured

I have an HSA or FSA

Health Savings or Flexible Spending Account — can often be used for doula services

4

Referral source

Were you referred to UDAP? select one

5

Circumstances & services

Public benefits enrolled in select all that apply

WIC (Women, Infants & Children)

SNAP / Food Stamps

Housing assistance or Section 8

None of the above

Current barriers select all that apply

Significant medical debt or bills

Housing instability

Domestic violence situation

In recovery from substance use

Reentry after incarceration

None of the above

Services interested in select all that apply

Birth doula support (labor & delivery)

Postpartum doula support

Childbirth education

Advocacy & navigation support

Not sure yet — help me understand my options

6

Anything else