Form

ASAP! Lactation/Feeding Support

In-Home
What's Included:

Up to two hours of Lactation/Feeding support in your home. Texting/email/phone follow-ups.

If an in-home follow-up is requested there is a $100 service charge

This may include, but not limited to:
- Review Pregnancy & Birth Story
- Help form your nesting space at home
- Observing breastfeeding
- Latch and Positioning
- Milk Transfer
- Milk Supply Guidance
- Sore Nipples
- Over Supply or Under Supply management
- Plugged Ducts
- Safe Sleep Environment
- Infant Nutrition
- Parent Nutrition
- Hand Expression
- Pumping, flange sizing, pump settings
- Skin to Skin
- Breast Massage
- Baby Wearing
- Returning to Work
- Breastfeeding and Supplementation
- Weight checks
- Weighted feeds
- Counseling and empowerment
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Partner's Name (If applicable)

First NameLast Name
Baby's Name

First NameLast Name
Baby's birth date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client understands that the total fee of $225 is due upon receiving invoice
Client Initial
Client and Doula/Lactation Counselor (Kristen) are committed to promoting a safe home/work environment in which all those who enter the home will conduct themselves in a civil, respectful, and cooperative manner. Any disrespectful, aggressive or verbal/physical abuse by the client will result in Kristen immediately leaving the premise, terminating the service and forfeit of all fees.
Client Inital
Sometimes Kristen will not be able to provide services as scheduled, due to unforeseen circumstances (i.e. family emergency, illness, or a client birth). Kristen will make every effort to reschedule the meeting in the most timely matter.
Client Initial
Kristen does not work holidays (New Year's Eve, New Year's Day, Easter, Christmas Eve, Christmas, Memorial Day, July 4th, Labor Day, day before Thanksgiving, Thanksgiving, and March 4th, May 3rd, June 23rd, and July 6th)
Client Initial
Client

I agree to the terms of this contract
Client Name

First NameLast Name
Current Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client Signature
Doula/Lactation Counselor Name

First NameLast Name
Current Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Doula/Lactation Counselor Signature
Should be Empty:

ASAP! Lactation/Feeding Support

Client