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End-of-Life Doula Membership Form
Annual Membership Fee
*
$50
Your credit card will be renewed automatically on your sign-up date to ensure your membership for the next year.
Yearly
Name
*
First Name
Last Name
Professional Degree / Credential Abbreviations (ie. RN, PhD, JD, MSW)
Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Phone
*
This will be the one used in the doula directory
Geographical Service Area
*
If applicable, this will be the used in the doula directory. Example: specific county served
Email
*
This will be the one used in the doula directory
Website, beginning with http://www.
Gender
*
select one
Female
Male
Transgender
Non Binary
Gender Variant/Non-Conforming
Other
Prefer Not to Answer
Age Range
*
select one
18 - 25
26 - 35
36 - 50
51 - 60
60+
Race / Ethnicity
*
Check all that apply
Caucasian
African American /Black
Latinx
Native American
Asian
Bi-Racial
Multi-Racial
Other
Prefer not to answer
Education Level
*
select one
Did not graduate from High School
High School Graduate or GED
Some College
College Degree
Graduate School
Professional Degree
Current Occupation
*
Household Income
*
select one
Less than $10,000
$10,000 - $25,000
$25,000 - $50,000
$50,000 - 100,000
$100,000 - $150,000
Over $150,000
Prefer not to answer
Percentage of Income From Doula-related Work
*
Please list the percentage of your household income that comes from your doula work
Professional Titles
*
Check all that apply
Nurse -- RN
Nurse -- LPN
Nursing Administrator
Ordained Clergy
Celebrant
Chaplain
Social Worker
Life Coach
Physician
Birth/Postpartum Doula
Licensed Massage Therapist
Psychotherapist/MSW/LCSW
Energy Medicine
Oriental/Ayurveda/Functional Medicine
First Responder/Paramedic
Herbalist/Aromatherapist
Lawyer
Accountant
Home Funeral Guide
Funeral Director
Ceremonialist
Hospice Executive
Other
Your Payment Structure
*
Check all that apply
Services provided at no charge
Donation determined by client
Fee for service
Sliding scale
Barter
Services paid by umbrella organization
Volunteer within community organization
Volunteer within Hospice
Other
Services You Currently Offer
*
Please check all that apply
Advance Care Planning
Early diagnosis (palliative)
Vigiling/Active dying attendance
After death care/home funeral
Bereavement involvement
Community EOL education (non-doula specific)
Celebrant/minister
Energy medicine
Green burial education
Legacy projects/planning
Massage therapy
Organizing/downsizing/moving
Perinatal involvement
Personal Caregiver
Practical household help (meals, pet/house sitting, rides, etc.)
Reiki/Healing or Therapeutic touch
Respite services
Threshold Choir
I am joining NEDA because:
*
Please top five
I am an aspiring EOLD
I have worked in a profession closely associated with EOLD and want to see it grow
I have benefited from doula services in the past
To learn more about the field of end of life doulas
To access written/published resources and online education, such as webinars
To become NEDA Proficient
To get referrals from prospective clients because of being listed in the NEDA online directory
To network with other EOLDs and professionals in the field
Being NEDA member lends credibility to my work
To have access to the social media closed EOLD groups (such as the NEDA Member Facebook page)
I would like to be involved with NEDA as a volunteer:
Please check all that apply
I have interpersonal/leadership skills
I have organizational skills
I have media/publicity skills
I have writing skills
I have public speaking skills
I have technological skills (i.e., website or database maintenance, etc.)
I have networking skills (building bridges with individuals and other orgs.)
I have fundraising/development skills
I have administrative skills
How Do You Hear About NEDA?
Please check all that apply
EOLD Training
NEDA Website
NEDA Newsletter
FaceBook Page
A Friend
Google Search
Other
NEDA End-of-Life Doula Directory
*
I acknowledge that by agreeing to have my contact information listed on the NEDA Online Directory I may be contacted by individuals, companies, or groups not associated with NEDA. My contact information will be public and cannot be controlled by NEDA.
Yes, I want to be included in the website Directory.
No, I do not want to be included in the website Directory
NEDA Regional Group Contact Information Sharing
*
Yes, I give permission to share my email address with other NEDA members interested in forming regional groups
No, I do not give permission to share my email address with other NEDA members interested in forming regional groups
Upload Head Shot Photo
*
Please use a professional head shot, if possible.
Directory Agreement
*
"By clicking the box below, I am indicating that I understand and accept the following terms: 1) Inclusion of my information on the website directory does not constitute endorsement by NEDA or my training organization, if I have one. 2) I am fully responsible for my own contracts, promotion, and interaction with the public. 3) I have read and agree to honor the NEDA Code of Ethics, Conduct, and Scope of Practice. 4) I understand that my listing on the website directory will only be included as long as I am an active member of NEDA (renew each year)."
Yes, I agree
Add 3% to my total amount to help cover the payment processing fees
