Postpartum Doula Agreement

Today's date*

MonthDayYear
Parent 1 Information
Parent's Name*

First NameLast Name
Pronouns*
Parent's Phone #*

Area CodePhone Number
Parent's E-mail*
example@example.com
Preferred Method of Communication*

EmailPhoneText
Parent 2 Information
Parent's Name

First NameLast Name
Pronouns
Parent's Phone #

Area CodePhone Number
Parent's E-mail
example@example.com
Preferred Method of Communication

EmailPhoneText
Family Details
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Emergency Contact's Name*

First NameLast Name
Emergency Contact's Phone Number*

Area CodePhone Number
Baby's Due Date or Birthdate*

MonthDayYear
Date
Baby's Name*
Names, ages, and pronouns of other children
Birth Location*
Primary Care Provider*
Other Providers
Anticipated Support Needs:*

MorningAfternoonEveningOvernightOther
When is your ideal start date to begin receiving care?*
Additional requests and needs from your family:
Agreement and Consent
I have read the letter describing postpartum services and agree that it accurately reflects the expectations I have of a doula-client relationship with Mel Swanson. I have read all statements contained herein and acknowledge that I am signing a complete release and bar to any claims which I have, or believe I may have, resulting from our contract for postpartum doula services.

This contract is valid for six (6) months, after which we may renegotiate or extend this agreement together.
Please draw your signatures.*

Clear
Should be Empty:

Parent 1 Information

Parent 2 Information

Family Details

Agreement and Consent