Birth Doula Service Description and Agreement
As a birth professional, I am dedicated to supporting and empowering women and families during the childbearing year. This service description and agreement explains my scope of practice and our agreement to work together before, during, and after the birth of your baby.
- My Role as a Birth Doula. I am a professionally trained childbirth coach who helps a mother during pregnancy, throughout labor, and after birth to provide emotional, physical, and informational support. During pregnancy, I assist you with discovering your concerns and preferences about childbirth and provide information about holistic and natural remedies to minor pregnancy discomforts. I may also use relaxation techniques such as massage, acupressure, other physical comfort measures and breathing techniques prior to and during your birth.
- My Services. I provide support via email, text, and phone, addressing any concerns you may have about your pregnancy and upcoming birth. We will have two prenatal visits (for the Birth Beginnings Doula package), I will attend your birth, and we will meet for one (1) postpartum in-person visit* and one (1) virtual visit. I would be happy to accompany you to one of your prenatal visits with your primary care provider if you wish and if I have availability. At these meetings we will accomplish the following:
- At the first prenatal visit, I will gather information about you and your concerns about and preferences for your birth. We will also discuss procedures for contacting me at the onset of your labor. Based on a questionnaire you complete prior to our visit, I will offer you some resources for you to review prior to our next visit.
- During the last four weeks of your pregnancy, we will meet to discuss your birth plan, practice comfort measures and ways your partner can support you during labor and answer your questions.
- When you believe you are in your labor, you will call me, and I will plan to meet you 60-90 minutes from the time you request my presence either at your home, the birth center, or hospital.
- Within the last two weeks of your pregnancy, we will schedule the postpartum visit to have a post-birth experience check-in and to visit with you/baby and any post-delivery concerns.
- I will remain with you throughout your labor and up to two hours after the birth*. If desired, I can assist you with initiating breastfeeding.
- Within the first two weeks postpartum, we will schedule our final visit, which will be a virtual visit to discuss any questions you may have and follow up on mental well-being.
*Due to COVID-19, restrictions may apply on whether visits will be in person or virtual. Restrictions may also be in place at the facility where you deliver that may or may not impact doula support. In this case virtual support will be provided via Google Duo or telephone but will be discussed at length during your 2nd prenatal visit.
- Your Responsibilities. You agree to participate in the planning of your birth and to communicate openly with me about any questions and concerns about your pregnancy and birth, including:
- Any special needs, health issues, medical conditions, emotional situations, or concerns
- Any medical procedures or hospital visits during your pregnancy
- Updates of your prenatal visits with your primary care provider
During the course of working with me, you may have the use of items that must be returned to me at the end of our working relationship. Items may include books, videos, a birth ball, or other tools to be used prenatally or during birth. You understand that if any of these items are damaged or lost, you are responsible for replacing or paying the value of the item to me.
- Confidentiality. You give me permission to take notes about you that you choose to disclose to me pertaining to you and your child with regard to your pregnancy, birth, postpartum period, and any prior birth experiences. You understand that this information may be used by me or any backup doula that cares for you and your family. You also understand that this information will anonymously be used for data collection for statistical purposes, and that I may use this information to provide you with a summary for your own personal use. You understand and acknowledge this and hereby consent to such use of your personal and medical information.
- Contacting Me. Beginning two weeks before your due date, I remain on-call 24 hours a day, 7 days a week, and expect to be notified at the onset of your labor. If you go into you labor prior to 38 weeks, I will still be available. You will receive my contact information from me at our first prenatal visit. I must be notified early in your labor or if your water has broken to allow time for me to arrange to meet you at home or the hospital/birth center.
- Backup Doula. In the event that I cannot attend your birth due to illness, an unusually long labor, or another emergency, a backup doula will be provided. I will compensate her directly for attending your birth.
- Fees. My fees are outlined below. A detailed description of my fees is included separately in my Menu of Services. I accept cash, personal checks, or online payment via Square. A $25 returned check fee applies.
Please select one of the following Service Packages or Ad Hoc Services:
❖ Birth Beginnings Doula Package- $1475
❖ Birth Now Doula Support- $850
❖ Circle of Birth-to-New Mom Coaching - $395 _______
❖ Labor Comfort Measures Coaching - $150 _______
❖ Chat with the Doula - $45 _______
Payment terms are as follows:
❖ Upon signing this agreement, you will pay a 25% non-refundable Prenatal and Postpartum Services Fee. ❖ The remaining 75% balance is a Birth Support Services Fee and is due by the 36th week of pregnancy or the second prenatal visit, whichever is later.
❖ The option to pay in full at the time of signing this agreement is also accepted and welcomed.
- Other Providers’ Charges. Any medical services you receive by medical providers, holistic care providers or other pregnancy- or labor-related expenses incurred during the pregnancy or the birth are your responsibility.
- Unexpected Circumstances and Termination of Services.
- If my failure to attend your birth is due to circumstances beyond anyone's control (i.e. situations like COVID-19), your failure to contact me, or you do not contact me in time to arrive at the birth, no refund is due. In the event that this occurs, I am happy to schedule a second post-par tum visit.
- If my failure to attend your birth is due to my error, I will refund the Birth Support Services fee, unless a backup doula has been arranged for you.
- You may decide not to use my services for any reason, and you may terminate this agreement by notifying me in writing. You will forfeit any payments you have issued to me at the time of termination.
- I may terminate this agreement at any time for any personal medical or family emergencies, if you fail to keep your appointments, you do not make timely payments or you engage in any drug or alcohol abuse or other behaviors that put you or your baby at risk during your pregnancy.
- Insurance. You understand that I do not accept insurance, but I will provide you with receipts that you may submit to your insurance company or employer health savings plan. I cannot guarantee that the insurance company or health savings plan will reimburse you for my fees or for any related expenses you may incur for the pregnancy and birth.
- Understanding of Services. You understand that as a birth doula:
- I do not function in the capacity of a trained medical specialty as a health care professional and do not perform medical assessments or medical procedures. My role is to provide services of support, encouragement, and supplemental education.
- I do not make decisions for you. I will help you get the information necessary to make your own informed decisions. I will also remind you if there is a departure from your Birth Preferences/Plan.
- I will not speak for you to medical staff regarding matters where health care decisions are being made. I will discuss your concerns with you, and when asked, suggest options. I can support you in discussions with staff as your advocate, making sure you have the opportunity to discuss any concerns. You or your partner will speak on your own behalf and make decisions for yourselves.
You understand that birth is a natural process, and in order to have the birth you desire, you must be willing to participate fully in education, prenatal meetings, and communication with all who are involved. You accept full responsibility for the decisions that are made on your or your child’s behalf and recognize that a variety of unforeseen circumstances could arise during pregnancy or your labor that require medical intervention or emergency medical treatment which could preclude your ability to have the delivery and outcome you desired or expressed in your Birth Preferences/Plan. You acknowledge that these events are out of my control. You understand that you assume primary responsibility for the birth of your child and to the extent permitted by law, you will not hold me or my practice responsible for any outcomes resulting from complications that are outside my control.
You acknowledge that you understand these risks by initialing here. _____________
- Entire Agreement. This agreement reflects the entire understanding between us and may only be changed in writing and signed by both of us. If any of the terms are considered enforceable by a court, we agree that these terms will be severable from the agreement and all other terms of our agreement will remain in effect.
Please acknowledge your agreement and understanding of these terms by signing below. Client’s Signature: Date: Partner’s Signature: Date: Doula’s Signature: Date:
Doula’s Name: Yvette Wright
Email Address: email@example.com
Website Address: www.circleofbirthdoula.com
Birth Beginnings Doula Package: ____ Birth Now Doula Support: ____
Ad Hoc Services Selected:
Labor Comfort Measures Coaching: ____
Circle of Birth-to-New Mom Life Coaching: ____
Chat with the Doula: ____
Date Deposit Paid: Amount: FOP/conf#:
Date Balance Paid: Amount: FOP/conf#:
Menu of Services
Birth Beginnings Doula Package $1475
∙ Two prenatal visits to assess your needs and desires for birth, define and understand our expectations of one another, and education on comfort techniques for labor
∙ Birth preferences assistance to help you clarify your preferences for birth and explain the options that are available to you ∙ Prenatal health education
∙ Continuous physical, emotional, and informational support to you and your partner for the duration of labor and birth, to help you hold and move towards the vision you created for your baby's birth
∙ Initial breastfeeding support immediately after birth to help your baby latch on properly and encourage establishment of breastfeeding
∙ Two postpartum follow-up visits (1 in-person visit and 1 virtual visit) to celebrate the birth of your baby, answer any questions you have during the early postpartum period, provide education on newborn care and review of signs of postpartum complications, including postpartum depression and anxiety.
∙ Unlimited phone, text, and e-mail support to answer your questions and offer suggestions and support throughout pregnancy and early labor
Birth Now Doula Support $850
Ideal for the pregnant woman that only wants day of delivery advocacy and support from the doula. Expectant mother will contract with doula by 36 weeks’ gestation and doula will provide labor/delivery doula coaching, support, and advocacy on the day of labor/delivery.
Doula and client will have 1 meeting (in person or via phone/email) to discuss birth plan and desires for delivery. *Mom can add (2) follow-up postpartum visits for additional $100
Ad Hoc Services
Circle of Birth-to-New Mom Life Coaching – (4) 30-minute sessions by phone - $395
o Address concerns around delivery, birth, and parenting.
o Create a plan of action to support the various transitions that occur following birth, bonding, feeling supported and encouraged during the postpartum period
o Create a plan for stress reduction
Labor Comfort Measures Coaching: (2) 30-minute visits virtually or at client’s home $150
o Ideal for a pregnant woman that only wants to focus on techniques to use without the support of a doula. Doula will meet with client to teach and review various labor comfort techniques and help the client select ideal techniques (i.e. aromatherapy, touch, physical activity, mindfulness, etc.) for their use during their upcoming delivery. *This will be interactive instruction. Support person encouraged to attend.
Chat with the Doula (Telephonic or In-person) 15-minute session $45
Ideal for a pregnant woman that is not desiring doula services but needs occasional support and coaching during the pregnancy or postpartum period. Nervous about the birthing process? Need questions answered?
Have the presence of a doula that offers emotional and educational support and addresses your questions and concerns while providing guidance during the pregnancy and/or postpartum period.
∙ Upon signing this agreement, you will pay a 25% non-refundable Prenatal and Postpartum Services Fee. ∙ The remaining 75% balance is a Birth Support Services Fee and is due by the 36th week of pregnancy or the second prenatal visit, whichever is later.
∙ Credit card payment through Square is accepted. Payment through CashApp is accepted.