Postpartum Doula Agreement

Today's date*

MonthDayYear

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's Name

First NameLast Name

Pronouns

Parent's Phone #

Area CodePhone Number

Parent's E-mail

example@example.com

Preferred method of communication

EmailPhoneText

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

Due date or Birthdate*

Date

Baby's Name*

Names, ages, and pronouns of other children

Birth Location*

Primary Care Provider*

Other Providers

Anticipated Needs*

Hourly Support - out of package hours to be determined as needed: 4 hour minimumDaytime Support Package - Minimum 12 hours to bookOvernight Support Package - Minimum 24 hours to bookSuggested care for recovery - 16 hours of overnight support and 8 hours of daytime supportMorningAfternoonEveningOvernight

When is your ideal start date to begin receiving care?*

Additional requests and needs from your family:

I have read this letter describing postpartum services and agree it reflects the expectations I have of a doula-client

agreement with Mel. I have read all statements contained herein and I am aware that we are 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 the duration of 6 months, after which we may re-negotiate another contract together or extend this version.

Draw your signature into the box below.*