Contract for Birth Doula Services

My goal is to provide holistic, comprehensive emotional and physical support for the birthing person and their partner. I’m honored and grateful to be allowed to share this special time with your family. Throughout your pregnancy, I will provide resources and information to help you prepare for your upcoming birth. During your labor and birth, I will be an important member of your support team, helping you to feel confident, supported, informed, and respected.

22Questions

1
Birthing Person
First Name
Last Name
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2
Birthing Partner
First Name
Last Name
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3
AddressPlease list the address where prenatal visits will be held.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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4
Birthing Person's Email
example@example.com
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5
Birthing Partner's Email
example@example.com
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6
Birthing Person's Phone Number
Area Code
Phone Number
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7
Birthing Partner's Phone Number
Area Code
Phone Number
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8
Birthing Person's EDDEstimated Due Date
Date
Year
Month
Day
Date
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9
Place of DeliveryPlease provide the gps address as well as any relevant arrival information.
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10
Does the birthing person have any history of depression or anxiety?
YESNO
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11
Initials* This field is requiredPlease initial your acknowledgement of the Fees portion of the contract.
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12
Initials* This field is requiredPlease initial your acknowledgement of the Cancellation portion of the contract.
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13
In the event that I cannot attend your birth, would you prefer(At your request, I will attempt to secure backup doula support but their availability is not guaranteed by this contract. Backup arrangements are more difficult to secure later in pregnancy or for contracts with special payment arrangements.)
additional postpartum support
backup doula support
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14
Contracted ServicesI/We___________________________________________am/are hiring Well-Rounded Woman Care LLC for Birth Doula Support and agree to pay for services as outlined.
Name(s)
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15
Initials* This field is requiredPlease initial your acknowledgement of the Limitations portion of the contract.
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16
In entering a contract for birth doula support with Well-Rounded Woman Care LLC, I/We hereby acknowledge that during the performance period of this contract, services may be provided to me/us in my/our home. I/We understand that Well-Rounded Woman Care LLC has a limited role as per the description of tasks outlined in the above-referenced contract wherever services are provided to me/us.* This field is requiredPlease initial acknowledging this waiver of liability.
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17
Well-Rounded Woman Care LLC has not represented to me/us that contracting for services guarantees in any way a risk-free or emergency-free birth experience. I/We understand that my/our doula does not make medical decisions on my/our behalf, to include the decision when to seek medical care.* This field is requiredPlease initial acknowledging this waiver of liability.
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18
When services are performed in a medical facility, I/we acknowledge that Well-Rounded Woman Care LLC is not responsible for the performance of clinical tasks to include medical decisions regarding the inclusion or exclusion of treatments available to me/us and my/our baby.* This field is requiredPlease initial acknowledging this waiver of liability.
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19
I/we acknowledge that any personal care products (including but not limited to essential oils, herbs, or care products for birthing person and baby) are used at my/our own risk. Our doula prepares or purchases these products with the highest quality, therapeutic grade, and organic ingredients whenever possible and has personally used them herself or with her own children; however, she IS NOT a certified herbalist or essential oil distributor.* This field is requiredPlease initial acknowledging this waiver of liability.
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20
Now, therefore, in consideration of the above acknowledgements, I/we (both jointly and separately) on behalf of myself/ourselves, my/our heirs/administrators/personal representatives/executors/assigns to RELEASE AND FOREVER DISCHARGE Well-Rounded Woman Care LLC from all damages or causes of actions, either at law or in equity, which I/we may have or acquire or which may accrue as a result of using the doula services of Well-Rounded Woman Care LLC. I/We intend this to be a COMPLETE RELEASE AND DISCHARGE from all liability whatsoever.* This field is requiredPlease initial acknowledging this waiver of liability.
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21
I/We have read all statements contained herein and I/we fully realize that I/we are signing a COMPLETE RELEASE AND BAR to any claims which I/we have or believe I/we have resulting from our contract for doula services.* This field is requiredPlease initial acknowledging this waiver of liability.
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22
Agreement & SignatureIn signing this contract, I/we agree to to the terms of payment, services as described in the above contract, and release of liability.
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