Birth Doula Registration Form

I am independently employed; I work for you, not your doctor, midwife, or hospital.

I will meet with you one to two times prenatally, at mutually agreeable times. During these visits, we can discuss any questions you might have, and review your birth plan which will help organize your thoughts about what is important to you and help communicate your wishes to your medical caregivers. It would be helpful if both you and your partner or other birth companion can be present at these meetings. Additional visits can be arranged at an additional hourly charge.

During pregnancy, I will follow up with you at around the following milestones via text to check in on you if I have not heard from you:

8 weeks, 12 weeks, 16 weeks, 20 weeks, 24 weeks, 30 weeks, 32 weeks, 34 weeks, 36 weeks, 38 weeks, 40 weeks

I can provide information on options for your birth plan. However, you will be responsible for deciding on a birth plan that is best suited to your individual needs and preferences and for discussing the terms with your doctor.

I will remain with you, as long as possible from the time you request me to be with you once labor has begun, until one to two hours after your baby is born, apart from short breaks for meals and rest as time allows. Longer breaks, for instance if you first call me in early labor, may be taken at mutually agreed upon times.

I can help you to utilize non-medical support techniques for labor and birth, such as breathing techniques, massage, heat packs, bath or shower, positioning, et cetera.

I will maintain a birth log, as circumstances allow, of the events that occur during labor and birth. I will strive to be as accurate as possible in recording the entries, but I can provide no guarantees in this respect. If you request them, I will provide a written record of your birth based on these notes within two weeks of the birth of your baby. All records remain confidential. I will not share these records with any person, except where disclosure is required by law.

I will help you initiate breastfeeding if that is what you choose to do. I am not a certified lactation consultant.  If you wish to bottle feed your baby, I can help with the first feeding if required.

After the birth I will make one postpartum visit which can be anywhere from one to two weeks after birth. I will strive to answer any questions or connect you with another professional where appropriate. Additional postnatal visits can be arranged for an additional hourly charge.

I will not make decisions for you. I will provide information that may be helpful for you and/or your partner to make an informed choice.

I will not perform clinical tasks such as assessing blood pressure, checking the dilation of the cervix, monitoring the fetal heart rate, making any medical diagnosis, administering or prescribing medication, or any other procedure that qualifies as practicing medicine. My role is limited to providing for your physical, emotional, and educational support.

I will not provide medical advice or advice concerning any alternative therapies. Any information I provide should in no way be construed as medical advice and is not a substitute for medical advice, which only a licensed medical practitioner can provide. It is your responsibility to seek the advice of an appropriately qualified practitioner in case of doubt.

I will not speak to your medical caregivers on your behalf. I can discuss your concerns with you and provide information on options that may be available to help you with composing questions for you to ask your caregivers, but you or your partner will be responsible for communicating your needs to the medical staff.

I am not licensed or permitted to deliver your baby or to perform any clinical skills related to the delivery of your baby. In the event that the baby arrives unexpectedly at home without a licensed medical practitioner in attendance, you or your partner or other attendant will be responsible for catching the baby as they are born. However, should your partner or attendant not be available to catch the baby as they are born, and if you are unable to do so yourself, then with your consent I may take on this role.

You will complete a written birth preference sheet and discuss it in detail with the medical practitioner scheduled to attend your birth. You will make the necessary arrangements to tour your proposed birth facility and will do so before the birth.

You will call me when you think you may be in labor, even if you are not sure, or as soon as your waters break so that I may make arrangements to attend your birth. I will provide support over the phone until you decide you would like me to be with you in person. If for any reason you are unable to contact me once labor has begun, you will leave a message for me and then contact your backup doula.

You will allow me approximately 30 to 90 minutes to reach you from the time you have informed me that you require my presence. Please ensure you have either spoken with me verbally, or received confirmation from me that I am aware that you are in labor. It is up to you and your partner to determine when you will leave for the hospital.

It is your responsibility to ensure that the necessary arrangements are made to have a medical practitioner present at the birth whether the birth is to be in the hospital or at your home.

A deposit of 50% is due within three days of submitting your registration form for booking a doula. The full balance is due no later than 34 weeks gestation. Payment must be made in full before I am able to be available on call for your birth.  The deposit is non refundable.

If you decide to cancel this contract after the following will apply:

• Cancellation more than twelve weeks before your due date: 50% refund of any funds paid beyond the initial deposit, less costs of any prenatal visits made or childbirth class completed. The cost of each prenatal visit and childbirth class for this purpose is $125/each.
• Cancellation between twelve weeks and six weeks before your due date: 25% refund of any funds paid beyond the initial deposit, less costs of any prenatal visits made or childbirth class completed. The cost of each prenatal visit and childbirth class for this purpose is $80/each.
• Cancellation less than six weeks before your due date: no refund.

If you need an alternative payment arrangement, please discuss with Stork Helpers at your initial consult.  We will try to work out an alternative payment arrangement if possible provided that all fees are still covered by no later than 32 weeks for a singleton pregnancy or 24 weeks for a multiple pregnancy.

If I am unable to attend your birth due to hospital visitor restrictions, I will continue to support you before and after birth and can provide virtual support during delivery (e.g. phone, text, Skype, Zoom, etc).  

In many cases, hospital restrictions are typically not an issue, however during COVID-19 many new restrictions were put into place temporarily, some of which directly affected doulas.  Refunds will not be issued due to a change/update in hospital visitor restrictions as it is not a situation that I can control.  

I will make every effort to provide the services described herein. In the case of circumstances beyond anyone's control, including but not limited to a rapid birth or medical emergency, it may be impossible for me to provide these services. No refund will apply.

If you call in good time and advise that you are in labor, but neither I nor your back-up doula attend your birth due to an error on our part (such as losing or inadvertently turning off our cell phones, or missing your call) I will refund the total amount paid less the cost of any prenatal care already provided and any postpartum care desired. If you are unable to contact me you are required to leave me a message on my cell phone, and then to contact your backup doula both at home and on their cell phone, leaving a message on their cell phone as well.

If you fail to call me and/or your back-up doula to advise us that you are in labor, for whatever reason, you will not be due a refund of amounts paid. If there is a remaining balance outstanding, this will be due.

Due to the HIPAA regulations, please understand that I do take notes about you or your birth and/or postpartum experiences.   This information may include information about your pregnancy, birth, and postpartum experiences.

I do not share this information and these notes are kept for my personal reference through your pregnancy, birth and postpartum experience.

I often use photographs of the families I have worked with so that prospective clients can see for themselves a little bit of what it’s like to have the support of a doula. I am grateful to those clients who have agreed to allow me to use photographs of themselves and their beautiful babies. If you would be happy for me to use photographs from your pregnancy or birth in this way, please indicate below.

If permission is granted photography may be used for but not limited to, our website, marketing or educational materials, social media platforms, etc.

To the fullest extent permitted by applicable laws, my liability for any and all claims, losses, expenses, injuries, or damages related to the performance of services under this contract of whatsoever nature and howsoever arising whether in tort or in contract or otherwise shall be limited to the amount paid by the pursuant of this contract.

I will not be liable for any direct, indirect, incidental, special, or consequential damages, resulting from the provisioner non-provision of services under this contract, even if the possibility of such damages has been specifically advised.

In signing this contract, you agree that you understand and agree with all the points herein. You further agree that you have been given the opportunity to raise any questions that you might have concerning my services and that these questions have been answered to your satisfaction.