Labor Doula Agreement Labor Doula Agreement Form We are honored to be a part of your journey into parenthood! This form helps us clarify our role as your doula support, and to secure your spot on our calendar, we need this form to be complete in addition to receiving a $250 deposit toward the total doula fee. After submitting this form you will be redirected to a page to complete payment via Paypal. Before purchasing labor doula services, you need to make sure the doula is available for your due date. You can learn more about our doulas on our meet us page and email us with your interest. Alternatively, we host a gathering of doulas and perspective clients every other month. Check our events page to learn about upcoming gatherings. Name* First Last Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Email* Enter Email Confirm Email Estimated Due Date*Location for Birth*Midwife/OB Group*DoulaPlease type your initials after reading the text below:*A Doula Is: A woman who accompanies women in labor to help provide a gentle birth experience. By drawing on our knowledge and experience, we provide emotional support, physical comfort and help to insure you have the information you need to make informed decisions in labor. We can provide reassurance and perspective to you and your partner, make suggestions for labor progress, and help with relaxation, movement, and massage.Please type your initials after reading the text below:*Doulas DO NOT: We do not perform medical tasks such as blood pressure checks, fetal heart checks, or vaginal exams. Doulas do not make decisions for you or speak for you. We do not come between you and your provider. Please type your initials after reading the text below:*Planning Meeting: We like to meet with you and your labor partner at least once before labor to become better acquainted, to explore and discuss your birth priorities and any fears or concerns, As a team we will determine how we might best work together. We love staying in touch by phone, e-mail, or texts on a more frequent basis as your birth approaches. Please contact us after provider appointments to keep us abreast of any changes you may be having, such as inductions, due date changes, progress that makes labor more imminent.Please type your initials after reading the text below:*Availability: We will be on call for you 24 hours a day beginning two weeks before your ‘guess’ date until your baby’s birth. If your due date changes please alert us. In the unlikely event that we become unavailable for labor support because of illness or a family emergency, we will inform you immediately and provide a back up doula at no further expense to you. We do everything possible to stay completely available for this 4-week period of time. Should a baby choose to arrive before the official on-call period, a doula will certainly be available to serve you. Please type your initials after reading the text below:*After your birth: Your doula usually remains with you after birth until you are comfortable and your family is ready for quiet time. She will be available to help with initial breastfeeding, as needed. Once your doula has left, she will be available by phone or text to answer questions about the birth or your baby. She would like to get together with you again for a postnatal visit. (more on this below) Please type your initials after reading the text below:*Failure of doula to provide service: Your doula will make every effort to provide these services. If her failure to attend your birth is due to her or her back-up’s unavailability, all monies paid for services will be refunded. If it is due to your failure to call us, a precipitous birth, cancellation of our services after the 36th week of gestation, any circumstance out of her control, she will keep the full fee. We will have provided prenatal services, been on call and perhaps turned away other clients. If you cancel more than four weeks prior to your determined due date, any monies paid excluding the deposit will be refunded. We have an arrangement as emerge... to provide backup doula services if your primary doula is incapacitated or otherwise unavailable. You agree to use a back up doula if it becomes necessary to do so. This is rare and only for extreme situations.Please type your initials after reading the text below:*When labor begins - our arrival: We prefer that you call us when you think labor is beginning, if you cannot sleep. You can call us anytime you need us - no matter the time of day. We may answer questions and make suggestions over the phone. Together we will decide if we should meet then or wait for further change. Together we will also decide where to meet- at the hospital or your home. We will discuss this more at your planning meeting. We come to you as soon after your request as possible, usually within an hour. Depending upon location, weather, traffic and other unavoidable obstacles, sometimes that time limit is exceeded. Know we intend to get to you as quickly as we can once you need us.Please type your initials after reading the text below:*Photos: We may take photos with our camera at your birth as an additional service, but at no additional fee. We are not responsible for the quality of the photos taken. There may be circumstances that eliminate the possibility of capturing photos, but those are rare. At our post birth meeting, images will be given to you for you to share as you choose. We welcome any photos you choose to share with us to use in our blog, Facebook page, website, or marketing and will only do so with written permission. Please type your initials after reading the text below:*Birth Timeline: Some of our doulas take notes for a birth story or labor time line at no additional fee. We may be unable to take notes in rapid births or births where the mom needs our constant attention. Even though we may give you a labor time line, we strongly encourage you to write your own story. We can help fill in some details for that.Please type your initials after reading the text below:*Inductions: We will come when you need us. Due to the nature of inductions, it may be difficult to determine. We are prepared to wait for your call. We typically communicate frequently while you wait for your labor to begin in earnest. We offer tips and ideas during this time. Sometimes, depending on the type of induction that is planned, you may be at the hospital several hours or even longer without feeling any discomfort or needing your doula’s presence. Please type your initials after reading the text below:*Postnatal visit: We look forward to meeting with you after your early postpartum time, if you desire. That meeting gives your doula the opportunity to review your birth, snuggle your baby, and get feedback about her role in your labor and birth. As each family has different needs, we ask you to initiate contact and that you give us several dates and times that may work for you. Phone calls or texts after your birth to address specific needs are always welcomed. We avoid contacting you, since we are unsure when you may be resting or having some quiet time with your new baby. Some moms do not want a postpartum visit at all. We are more than happy to send you your birth notes and/or photos if this is the case. We provide it as a courtesy only. So, although the birth of your baby renders this agreement completed, if you choose to have your doula share your birth timeline and photos, contact her to arrange this. Signature (By typing your name in this box you are agreeing via electronic signature to the initialed passages above and the passage below)*Fees: To secure your doula, this agreement must accompany a $250 nonrefundable deposit. After submitting this form, you will be redirected to a page with a link to paypal to complete the agreement by submitting your deposit. You can pay towards your balance at anytime with a check, cash, or by submitting a payment to firstname.lastname@example.org via Paypal. The balance of the fee is due at 36 weeks gestation (34 weeks for twin births). Refunds of all but the deposit will be paid in the event of a planned cesarean birth or any release of your doula up until, but not after this 36 weeks gestation (34 wks for twins).