YOGILA HOLISTIC BODYWORK, HEALTHCARE, YOGA & DOULA SERVICE
BIRTH DOULA/LABOR SUPPORT CONTRACT
I, Gila H. Shire (DOULA) agree to provide ______________________________ (Clients Name
and birthday) with non-medical labor support for the labor and delivery of her child due ________________________, (Name and estimated due date). I agree to provide my client with non-medical labor support for her labor and delivery. As non-medical support, it is clearly understood that I will in no way direct the medical care of my client, nor will she or her family ask me to do so. It is also understood that I work only for my client, not the caregiver, the hospital, or the birth center.
* Prenatal visit, helping you create a vision for your delivery plus a birth preference/vision list. (aka ‘birth plan')
* Phone and email support as needed during pregnancy and immediately postpartum.
* Emotional, physical & spiritual support during labor and birth.
* Patient advocacy during labor and birth
* Providing a bottle of “Gentle Baby/Baby Soft” essential oil for birth and after.
* YoGila’s Yoga Nidra Meditation CD for you and baby.
*A postpartum visit sometime between the first two-four weeks after birth to ask questions regarding the baby and lactation. We'll review your journey and allow you to reflect and give me feedback regarding my role in the experience.
The fee for the services described here is $_____, to be paid as follows:
— 50% as a non-refundable retainer fee, due when you sign this contract.
— 50% due by or at the postpartum visit.
Please note, that scheduling a c-section does not nullify this contract. If you choose not to have me attend your scheduled c-section, or your physician does not allow me to attend, you will not be refunded the retainer fee, however, you will not be charged the remaining balance due. If you have a c-section after receiving labor support, the remaining balance will be due.
I/We have read this contract describing the doula’s services and agree that it reflects the discussion we had with the doula.
I/We agree to payment for doula services as described above.
Signed (Client):__________________________________________ Date:___________
Signed (Spouse or Guardian):_______________________________ Date:___________
Signed (Gila H. Shire, LMT, Nurse,RYT)____________________________ Date:____________
I am looking forward to providing you with emotional and physical support, advocating your needs and wants and educating you to aid in your informed decisions about your birth. Some of the things I can provide are massage, music, aromatherapy, acupressure, help with relaxation and visualization, breathing techniques, advice on optimal fetal positioning, suggestions for labor positioning, hot/cold packs, assistance with staying hydrated and nourished, information on herbs and help with backache relief measures.
Printable version here.