Birth Doula Contract & Intake Form
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Due Date
-
Month
-
Day
Year
Date
Partner Involved
Yes
No
Prefer not to answer
Partner or Emergency Contact
Preferred Birth Location
Special Concerns
Health Conditions & Allergies
OBGYN/Midwife
Are you working with any other health care provider?
Yes
No
If Yes, please specify
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Scope of Services & Fee Details
Package Purchased
*
Full Journey
Third Trimester
Birth Only Support
Ala Carte
Medicaid Plan
Other
Services Included
24/7 Phone Support
Birth Plan & Review
Labor & Delivery Support
Prenatal Visit (1 hr)
Prenatal Visit (2 hr)
Postpartum Visit (2 hr)
Birth Photography (candid)
Comfort Measures Workshop
Partner Education
Birth Education
Pregnancy Education
Newborn Guidance
Postpartum Phone Support (til 6 weeks)
Postpartum Education
Present at Labor & Delivery
NON-Refundable Deposit
*
Remaining Amount Due Date
*
Refund Policy Acknowledgment
*
I acknowledge and accept the refund policy as stated in the contract
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Postpartum Preferences
Full Name
Areas to focus on during the fourth trimester
Movement/Exercise
Diet/Nutrition
Mental Health
Pain Relief
Emotional Support
Other
Other Concerns
Feeding
Breast
Bottle
Both
Pumping
Formula
Would like assistance from lactation consultant?
Yes
No
Other
I would like to go home as soon as possible
Yes
No
Is there anything you'd like to discuss during the postpartum period?
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Pregnancy Information & Birth Preferences
Expected Due Date
-
Month
-
Day
Year
Date
Sex of the Baby
Is this your 1st Pregnancy
*
Yes
No
Are you currently expecting more than one baby?
*
Yes
No
If yes, please specify
Have you ever experienced any pregnancy/birth complications?
*
Yes
No
If so, please specify
Have you ever experienced preterm births (before 37 weeks)?
*
Yes
No
If so, please specify
Please tick all the childbirth experiences you’ve had before
Unmedicated Natural birth
Home Birth Assisted
Birth Center Birth
Medicated Natural birth
Planned C-Section Birth
Hospital Birth
Water Birth
Unplanned C-Section
Unassisted
How are you planning to experience childbirth this time around?
Where are you planning to deliver at?
Do you have childcare planned already for your other children?
Yes
No
Do you have transport arranged to the delivery location?
Yes
No
If so, please specify
Will anyone else be involved in your labor and delivery?
Support Team & Emotional Support
Who is your primary support person during delivery and labor?
What role/responsibilities would you like this person to carry?
What role/responsibilities would you like your Birth Doula to carry?
*
What fears do you have about your pregnancy, labor, or delivery?
Are there any traumas you'd like to inform me about?
What comfort or pain management techniques would you prefer?
Epidural
Nitrous
Massage
Essential Oils
Position Changes
Pressure Points
Hip Squeezes
Breathing Techniques
Walking/Ball
Bath
Cool Compress
Warm Compress
10s Unit
Other
Are there any comfort techniques or labor/delivery positions that you want to avoid?
What concerns would you like to discuss during our prenatal visits?
What concerns would you like to discuss during our postpartum consultations?
Which informational resources would you find the most helpful?
Comfort Measures
Postpartum Recovery
Labor & Delivery
Diet/Nutrition
Exercise and Positions
Mental Health
Other
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Birth Plan Preferences
Delivery Method Preferences
Vaginal
VBAC
C-Section
Home Birth
Birth Center
Hospital
Air B & B
Water Birth
Epidural
Non-Medicated
Nitrous
Other
Labor Preferences
Change positions every 30 minutes
Movement and staying active
Use of birthing ball
Aromatherapy
Hip Squeezes
Bath/Shower
10s Unit
Dim lights
Music
Affrimations
No Talking
Comfort Measure Work Shop Techniques
Rest
Other
Birthing Positions
On my back
Hands and knees
Squatting
On my side
Other
Induction Preferences
Only if medically necessary
Open to it
Acceptable if recommended by doctor
No
Pushing Preferences
Directed pushing by medical staff
Follow my body's urges to push
Try different pushing positions
Prefer NOT to push on my back
See baby's head using mirror
Feel baby's head crown
Prefer to tear naturally & avoid episiotomy
Avoid forceps or vacuum use
Other
C-section Type
Planned C-section
Trial of Labor
Gentle C-section
Environment Preferences
Dim lighting
Calm and relaxing music
Scents and aromatherapy
Warmer temperature
Colder temperature
In my own clothes
Limited medical personnel checks/visitors
Photos/personal items
Pain Management Preferences
Epidural
Spinal
Combined
General
Nitrous
Techniques from Comfort Measure Workshop
Unsure
Health Conditions
Gestational diabetes
Group strep B
Herpes
Rh Incompatible
Epilepsy
Anemia
PTSD
Trauma
Other
Birth Experience Preferences
Modestly draped at all times
Partner present throughout
Permission to take videos and pictures
One hand free to touch the baby
Mirror provided to view the birth
I catch my baby
Partner Catch baby
No Students
Other
Immediately Post-Birth Preferences
Immediate skin-to-skin contact
Examine baby in my presence
Delayed cord clamping if possible
Partner cutting cord
First feeding as soon as possible
Delay first feeding until I’m settled
allow visitors/family in as soon as possible
Don’t bathe baby; we will do it ourselves
Keep Placenta
Look at Placenta
Golden Hour
Partner Skin to Skin
Other
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Agreement & Responsibilities Acknowledgment
Acknowledgment of Responsibilities
*
I understand the importance of openly communicating my concerns, needs, and preferences during pregnancy, labor, and postpartum.
I agree to notify the doula as soon as I think I’m going into labor.
I acknowledge the hospital regulations and will ensure the hospital consents to the doula’s presence.
I understand the service limitations of the doula.
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Liability Release and Photo/Video Release
Liability Release Agreement
*
I acknowledge that I have read and understood the liability release terms.
Photo and Video Release Agreement
*
I grant permission for photographs and video recordings to be taken and used as described.
I Do Not grant permission
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Confidentiality, Cancellation, Backup Doula, and Force Majeure Terms
Terms and Conditions Acknowledgment
*
I acknowledge and agree to the confidentiality terms as outlined.
I understand and accept the cancellation policy
I agree to the possibility of a backup doula being arranged if necessary.
I accept the force majeure clause regarding unforeseen circumstances.
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Dispute Resolution, Severability, Indemnification, Entire Agreement, and Signature Fields
Contract Clauses Acknowledgment
*
I acknowledge the dispute resolution process as outlined
I understand the severability clause
I agree to the indemnification terms
I accept the entire agreement clause
Client Signature
Date
-
Month
-
Day
Year
Date
Doula Signature
Date
-
Month
-
Day
Year
Date
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