Name *

First Name

Last Name

Phone *

(###)

###

####

Estimated Due Date *

MM

DD

YYYY

Is your due date within my availability windows? *

Yes – March 15 to July 10

Yes – September 10 to December 1

I’m not sure

No, my due date is in August or mid-Dec to early Jan (Please note I’m unavailable for these windows)

Please check each box to confirm you understand the terms of my doula support: *

I understand that this package includes two prenatal sessions, one postpartum session, and in-person birth attendance.

I understand that Kathleen does not offer translation services.

I understand that Kathleen does not attend prenatal medical appointments.

I understand that voice and text support is available during working hours until I reach 37 weeks pregnant, at which point Kathleen will be on-call and available to respond to calls at any time until the birth of until 42 weeks.

I am aware that this package includes a free 6-month membership to The Beehive.

I understand that due to Kathleen’s limited availability, applying does not guarantee a spot.

I understand that the limited time rate is ¥180,000 for the first three births and becomes ¥200,000 after.