Doula Service Contract

Doula Service Contract

BIRTH SUPPORT SERVICES

Contract Description and Agreement
My Role

I am a professionally trained childbirth coach that assists a mother and her support people with physical, emotional, and educational support throughout pregnancy and labor, and directly after the birth of her child. By completing this agreement you will receive empowerment services based on your SELECTED package. Please fill out this HIPPA compliant intake form and contract to continue.
Birthing Person*

First NameLast Name
Date Of Birth*

MonthDayYear
Date
Due Date*

MonthDayYear
Date
Last Menstrual Start Date*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthing Support (Partner, Spouse, Family Member, etc.)*

Full NamePhone Numer
Additional Birthing Support (Partner, Spouse, Family Member, etc.)*

Full NamePhone Numer
Emergency Contact (other than support person)*

Full Name Phone Number
Symphonic Birth Empowerment Services

I provide support via phone, text, video, and email about any concerns that you may have about your pregnancy and upcoming birth. We will have 1-2 prenatal appointments (as selected), I will attend your birth, and we will also meet for your selected amount of postpartum visits.

·        At the prenatal appointments, there will be several things to discuss in areas such as your specific birth plans, meditation and comfort measures support planning, and much more. We will also discuss procedures for contacting me at the onset of your labor.

·        Based on the information that I gather about you and from your intake questionnaire, I may offer resources and information for you to review in your own time.

·        In the case of virtual doula services, I will guide you through your labor process at home before going to the hospital or birth center. I will also remain with you virtually once you arrive there and during your birth.

·        I will remain with you throughout your labor and up to two hours after the birth, or until mom and baby are safe and stable. If desired, I can assist you with initiating breastfeeding.

· We will schedule our final appointment(s) to follow up with you and your new baby, discuss your birth experience, and answer any additional questions you may have within the first two weeks postpartum.
HSW Empowerment Package Selection

Use the menu below to select your support options. There is a Birth Hustle Workshop that is a requirement & is included in all of the support options.
Check the boxes below to choose your package options. *
Categories:All

All

Step 1: Doula Empowerment Support

Step 3: Choose Add-ons
prevnext( X )
Step 1: Doula Empowerment Support

Self -Empwrmnt (Labor Only)$700.00
Self- Empowerment is perfect for mommas that feel prepared, but would like coaching & advocacy support at their birth experience only. This service includes: Unlimited access to HER Virtual Birth Classroom, 1 prenatal appointment before birth, and physical support at & directly after her birth. This option is not available for first time, high risk, and/or v-back deliveries.

Gentle Empwrmnt $1,200.00
Gentle - Empowerment is perfect for mommas that wanting support through the delivery experience with full access. This service includes: Unlimited phone/text support, unlimited access to HER Virtual Birth Classroom, 2 prenatal appointments before birth (discussions of birth goals, health history, and plans of action.) Support at your birth and directly after, and 1 post-natal appointment.

Full Empwrmnt$1,400.00
Full Empowerment is perfect for momma's are looking for the full-on support through their entire journey leading up to, during, and after her birth. This service includes:Unlimited access to HER Virtual Birth Classroom24/7 unlimited phone/text support through 6 weeks postpartum, 2 preparation appointments before birth (discussion of birth goals, health history, plan of action, and other topics or concerns etc.), support at your birth and directly after, 3 post-birth appointments

Quantity

Step 3: Choose Add-ons

Reiki/Yoga Session$75.00
1 Personalized Service :1 session of either yoga or reiki personalized services.

Photo Package $50.00
Your beautiful pictures and videos captured during your labor and delivery.

Exclusive Offerings :$135.00
Currently 6-week yoga series. Online or in person. Ask about the next start date.

Personalized Service Pkg :$190.00
3 sessions of either yoga or reiki personalized services. You may mix and match sessions. Community Services :Currently 6-week yoga series. Online or in person. Ask about the next start date. Placenta Encapsulation :This is contracted to a professional doula encapsulator. If selected, a separate contract for encapsulation will be sent to you.

Placenta Encapsulation :$250.00
This is contracted to a professional doula encapsulator. If selected, a separate contract for encapsulation will be sent to you.

Total $0.00
Once your contract is submited you will receive an official invoice for your services. Your deposit amount is 50% of your package total to which you may pay directly through your invoice or you may submit via Zelle (hersacredway@gmail.com), Cashapp ($hersacredway), or Venmo @hersasacredway. Your services will begin once your deposit is paid. The remainder is due you 34th week gestation, or time of delivery ( whichever is earlier). Please consult with Her Sacred Way LLC.if further arrangements are needed.
Your Responsibilities

You are expected to complete any assignments or tasks given in regard to your birth. You agree to participate in the planning of your birth and to communicate openly and honestly with me about any questions or concerns regarding your pregnancy and birth. This includes:

·        Any special needs, health issues, pre-existing or new medical conditions, emotional situations, or other concerns.

·        Any medical procedures or hospital visits during your pregnancy.

·        Updates of all your prenatal visits with your care provider(s).
Backup Doula

I will make every effort to attend your birth as planned. However, if I cannot attend your birth due to illness, unusually long labor, or another emergency, a backup doula will be provided. You will be introduced to this doula before your due date. I will compensate them directly for attending your birth.
Unexpected Circumstances/Termination of Services.

If my failure to attend your birth is due to circumstances beyond anyone's control, your failure to contact me, or you do not contact me in time to arrive at the birth, no refund is due.

I may schedule additional post-partum visit(s) if this occurs,

·        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, fail to respond to communications, fail to make timely payments, or you engage in any drug or alcohol abuse or other life compromising behaviors that put you or your baby at risk during your pregnancy.
AgreeDo Not Agree
I Agree and It is okay to use my photo's and videosI Disagree to these terms and DO NOT want my photo or videos released
Total amount for your services and add-ons :
Deposit Amount:*
Date of 1st Payment /Service Start:*

MonthDayYear
Date
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: