BreastfeedLA Resource Directory Listing Application
RequiredRequired Question(s)
Thank you for your interest in being included in our Resource Directory. We hope to make this the most comprehensive resource of its kind in Los Angeles. To help us reach our goal, we are offering you a FREE posting until June 30, 2019. At that time you will have an opportunity to purchase a yearly subscription to be featured. Providers who offer free services are always included at no cost. 
 
1.
Please enter the information indicated below.

By entering my personal information, I consent to receive email communications from the survey author's organization based on the information collected.

First Name:
Last Name:
Company Name:
Work Phone:
Email Address:
emailaddress@xyz.com
Address 1:
Address 2:
City:
State/Province
(US/Canada):
Postal Code:

2.

Do you work for an organization or are you in private practice?

Organization
Private Practice
3.

If different from above, what is your business name as you would like it listed?

 

50 characters left.
4.
Please enter your website address, if applicable. 
 

50 characters left.
Required 5.
What is your profession? Please check all that apply.)


Pediatrician
OB/GYN
Nurse (RN, MSN, LVN, etc.)
Nurse Practitioner
Physician Assistant
IBCLC
Lactation Educator (CLEC, CLC, LES, etc.)
Doula
Midwife
Registered Dietitian or Nutritionist
Peer Counselor
La Leche League Leader
BreastfeedingUSA Counselor
Other  
6.

What certifications do you possess? List the type of certification(s) as written on your certificate, e.g. "certified lactation educator."

 

50 characters left.
7.
 If applicable, what is your license number / Expiration Date?
 

50 characters left.
8.
What type of services/
reimbursement do you provide? (click all that apply)


Free
Medi-Cal reimbursable
In-Network insurance accepted, please list below
Fee for Service/Out-of-Pocket
Other  
  • Comment:

  • 500 characters left.
9.

Are credit cards accepted?

Yes
No
10.
When are your services provided?


Weekdays
Weekends
Evenings
Other  
11.
What are your service hours?
 

50 characters left.
12.
In what languages are services provided? (Check all that apply)
English
Spanish
Chinese (Mandarin)
Chinese (Cantonese)
Japanese
Khmer
Tagalong
Vietnamese
Korean
Armenian
Persian
Other  
Required 13.

Which of the following do you or your organization offer? Please check all that apply.

Breast Pump Rental
Baby-Friendly Hospital
WIC Agency
1:1 Lactation Support
Breastfeeding Support Group
Breastfeeding Friendly Provider
Free or Low Cost Services
Other  
14.
Services:
Are Breastfeeding Classes offered? 


Yes
No
Other  
15.
Services Offered: Consults?


In Client Home
Your Office
Hospital Inpatient
Pediatric Office
WIC Center
Hospital Clinic
Other  
16.
Services Offered: Breast Pumps.


Purchase
Rentals
Pump related sales
Pump delivery
None
Other  
17.

Special breastfeeding services? (NICU graduates, teens, developmentally disabled, hearing impaired, in network insurance provider) 

 

50 characters left.
18.

Please share a short summary listing the services offered by your organization.

 

350 characters left.
Required 19.
Do you have a logo or image that you would like to feature on your directory listing? If so, please send the file in a high resolution JPG or EPS format to info@breastfeedLA.org. 
Yes
No
20.
How would you like to pay for your BreastfeedLA Resource Directory Listing
----FREE UNTIL JUNE 30, 2019----
 

50 characters left.