Please Print, Complete and sign form to complete enrollment:
My Role as a Doula:
As a birth doula, I accompany women in labor to help ensure a safe and satisfying birth experience. I have completed professional doula training approved by the Canadian Doula guidelines. I draw on my professional training, knowledge and experiences to provide physical, emotional, and educational support to women and partners. I can provide reassurance and perspective to you and your partner, make suggestions for labor progress, and help with relaxation, massage, positioning, and other techniques for comfort. I am independent and self-employed. As your doula, I am working for you, not your caregiver or the facility where you birth.
As a doula, I do not:
-Perform clinical tasks, such as blood pressure, fetal heart checks, vaginal exams, etc. I am there to provide only physical comfort, educational and emotional support.
-Make decisions for you. I will help you get the information necessary to make an informed decision. I will also remind you if there is a departure from your Birth Plan.
-Speak to the staff on your behalf regarding matters where health care decisions are being made. I will discuss your concerns with you and suggest options, but you or your partner will speak directly to the clinical staff.
Consultation: (1 hour)
It is very important that you and your partner are comfortable with me and with my role in the birth. Thus, I do expect to meet with clients once before labor to become acquainted, to explore and discuss your priorities and any fears or concerns, and to plan how we might best work together. This initial meeting is free and does not obligate you to use my services. If you choose to select me as your doula, I will want to become more familiar with your plans for labor, birth, and postpartum.
Prenatal meeting: (1 hour)
I prefer we arrange for 1 prenatal meeting before labor begins, preferably before 37 weeks in your pregnancy. Your husband/partner does not need to be present for this visit. This meeting gives us a chance to talk in detail about your preferences regarding your birth. If you have a Birth Plan, we will review it carefully. If you do not have a Birth Plan and would like to create one, I can assist with this then. I will want to know your own personal ways of coping with pain, fatigue and difficult situations, and what internal resources we can draw upon to assist you with the birthing experience. I will want to know how you and your partner foresee working together, and the roles of others who may be attending the birth. We can discuss together what concerns you have regarding the birth. We can review your preferences regarding the use of pain medications. My role is to help you have a satisfying birth as you define it. The more we explore this in advance, the better I will be able to fulfill this role. This contract will be signed at or before the first prenatal meeting. I will also inform you of times when I am unavailable for labor support.
I am available for phone consultations and email questions in pregnancy, and encourage clients to call with questions or updates. Once we enter the due date week, I encourage clients to check in with me every couple days to let me know how they’re doing.
When Labor Begins:
You will call me once you and your practitioner have decided you are reporting to your birthing place. I usually need approximately 2 hours to get to you from the time you ask me to come. We will also decide where to meet—at your home, the hospital or birthing center.
I will be your support for up to 12 contracted hours of face to face labor support.
Occasionally a woman will have something arise during her pregnancy that necessitates a scheduled Caesarean birth. If this decision is made four or more weeks before your due date, you may choose to cancel my Labor day services. I will refund you 1/2 of the total fee.
I will still come for 2 post-natal visits to your home.
Alternatively, you may choose to have me come with you to the hospital, accompany you during surgery or wait in the recovery room, and assist you with breastfeeding and adjustment in the first hours after your birth. In this instance my full fee will be due.
If your health care provider recommends an unscheduled caesarean at some time after labor has begun then the full fee is due as per our agreement.
I usually remain with you for at least an hour after birth, until you are comfortable and the family is ready for quiet time together. I can also help with initial breastfeeding, if necessary. I am available by phone or email to answer questions about the birth of your baby.
Postpartum visits: 2
-My services include 2 postpartum visits – 1 hour each visit, usually 2-5 days after the birth, and then a visit the following month. During these visits, I can provide breastfeeding support, baby care tips, and a chance to discuss the birth experience.
Waiver of Liability:
With my compliance to the description of services performed under this agreement, you agree on your own behalf to waive and herby do waive any rights claims or causes of action that you may have against me, your doula, now and in the future with respect to your pregnancy, birth, postpartum period and the services I may provide or fail to provide to you. You understand that, as a doula, I am not a medical professional, and therefore cannot and will not provide you with medical care or advice, but can give you resources to help you make your own educated decision.
Disclosure of communicable diseases
You agree to disclose any communicable diseases you have to me, so that I can choose to not take you as a client, or take appropriate precautions to protect myself.
I do not have a spleen and therefore I cannot subject myself to certain health risks.
The total fee for these services is $1,500. At the time we sign the contract at our prenatal visit, I ask for 2 checks each made out for the amount of $750 /each.
One for that prenatal date, and one post dated for your due date. This secures your birth on my calendar.
Additional labour support beyond the 12 contracted hours will be billed at the rate of $50 per hour.
The client is also responsible to pay for parking during the doula’s time at the Home/hospital. These fees will be billed after the delivery and payment is expected within 14 days of delivery date.
Failure to provide labor doula services:
I will make every effort to provide the services described here. Sometimes this is impossible for unforeseen reasons.
My refund policy is as follows:
If my failure to attend your birth is due to my error, there will be no charge for my services and I will refund all money.
If I miss your birth due to circumstances beyond anyone’s control (for example, extremely rapid labor), I will keep the first check, but there will be no further charges.
I will still attend both post-partum meetings with you.
If you fail to call me to attend your labor, there is no refund of the first check, but there will be no further charges. I will still attend both post-partum meetings at your home.
I have read and understand this contract, describing my doula services and agree to its terms.
Client’s Signature: Date:
Partner’s Signature: Date:
Teri-Dawn Milne, Date ___________
Contact Information and Location
Street Address, City, State, Zip Code
Phone Numbers (Home/ Cell)
_________________________________ Significant other’s Name
___________________________Significant other’s Phone Number
Labor and Delivery floor/location
Place of Birth
Street Address, City, State, Zip Code of Birthplace
*Circle One- for a history of or an expected quick labor (6 hours or less): YES/NO