HISTORY AND INFORMATION SHEET

2. Address: _______________________________________________________

3. Home Phone Number: _________________Business Phone Number _________

4. Number of Previous Pregnancies: ______Miscarriages _______Abortions______

5. Number of Living Children: _______ Premature births (<36 wks.)
___________

6. Have you ever had a C-section? If yes, what were the circumstances surrounding the decision to have a C-section?
_________________________________________ _________________________________________________________________ _________________________________________________________________

7. Have you ever had a V-BAC?
_________________________________________

8. Who is your careprovider and her/his name? Circle one (OB, Direct-entry Midwife, CNM, Family Practice MD, Other
_______________________________________________

9. Where do you plan to have your baby? (home, hospital, birth center)?____________

10. What is the name of the hospital/birth center?
______________________________ _________________________________________________________________

11. Many women today have been sexually abused. During labor and birth these issues can come into play. As your labor support person I may be of help during labor and delivery if I know this issue exists. If you feel comfortable in sharing this matter with me I will hold it confidential. You do not need to answer this question on this form.

12. Do you have any medical problems? If so, please explain. Use the back of this form if there is not enough room.
___________________________________________ _________________________________________________________________ _________________________________________________________________ 

13. Do you have any prenatal complications with this pregnancy: Yes No Group B Strep ____ ____ Pre-eclampsia ____ ____ Gest. Diabetes ____ ____ IUGR ____ ____ Mult. Pregnancy ____ ____ Preterm Labor ____ ____ Aids _____ _____ Herpes _____ _____ Other STD's ____ ____ Other (describe) ___________________________________________________ 14. What are your feelings about labor and delivery?
____________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________

15. What is your biggest fear about labor and delivery? __________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________

16. If you could labor and deliver your baby anywhere in the world and in any setting, not having to worry about the safety of you and your baby where would your fantasy birth take place?____________________________________________________
_________________________________________________________________ _________________________________________________________________ _________________________________________________________________

17. What kinds of sounds and smells would be surrounding you?
_________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________

18. When you are in pain what types of personal comforts do you like to use? Eg. A quiet room, heat, cold, words spoken, etc.
________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

19. Where do you hold tension in your body?
__________________________________ __________________________________________________________________ __________________________________________________________________ 

Professional Labor Assistant Services Contract

As your Professional Labor Assistant, my fees and services will be as stated in the following contract.

My total fee is $***.00 for my services. Of the $***.00, a non-refundable deposit of $50.00 is due at the first prenatal visit with the remaining balance due by either the final prenatal visit or actual birth, whichever comes first. This deposit will guarantee my availability to perform these services within, but not limited to 1 week prior and 2 weeks after stated due date.

For this fee you will receive certain services, however, it should be noted that my services in no way guarantees the medical outcome of this birth. Those services include, but are not limited to:

1. 3 Prenatal visits -

Visit #1: This is a day time visit . Its purpose is to educate me on how to get to your residence, to examine your kitchen cabinets for nutritional purposes, and to do an initial interview to determine your expectations of me and my expectations of you.

Visit #2: This is a night time visit. Its purpose is to familiarize me in my ability to find your home in the dark, a labor rehearsal (where we practice working together as a team), discuss your birth plan, and finalize arrangements such as when you will be expecting me to arrive and where certain items for laboring at home are located.

Visit #3: This visit is a daytime visit. Its purpose is to familiarize me with how to drive your car and which route to the hospital/birth center we will be taking when transportation is made if this is a hospital or birth center birth, or in case of emergency if this is a home birth.

2. Labor support for the birth itself - Jobs I will be performing at each birth besides supporting the laboring mother will include but not be limited to: making meals, preparing/retrieving ice chips, running bath water for mother, fielding phone calls, preparing/retrieving towels, massaging father's shoulders, assisting father, photographing/video taping, driving couple to place of birth, acting as liaison between medical attendants and laboring couple, keeping visitors to a minimum (and only those authorized by the couple to enter), informing the family of progress of birth process.

In the event of a marathon labor (labor lasting more than 24 hours) I reserve the right the call in my labor assistant for temporary relief at a cost of $10.00/hr. After a short respite, I will resume my primary role as your labor assistant. This is for your safety and mine so that I can perform at my optimum for the birth. Extra child care fees would be $30/day at the start of the 2nd day.

3. 1-2 Follow-up visits:

Visit #1: This visit will be made in the first 24-48 hours following the arrival of the mother at her home. Its purpose is to check on breastfeeding progress and determine what other services are needed at home (if any).

Visit #2: This visit will be made if there were problems at the first postpartum visit. Its purpose may also be to determine if mom is getting enough rest and baby is doing well.

Fees are final and may not be refunded unless I, , default on the contract.

In the event I am unable to attend a birth due to illness or other act of God the couple will be attended by the following backup assistant:

_________________________________________________________

This contract is drawn up and agreed to by the following persons as designated by their signatures below:

____________________________________________ Date:__________ Professional Labor Assistant 

_______________________________________ _______________________________________

(please print names here)
_______________________________________ _______________________________________

Signatures of Laboring Couple & Date

In response to requests I have received and to the recent post, I have made available a packet of forms for use in doula services. They are copyrighted and have been checked over by an attorney. The package includes, a face sheet, birth and postpartum fee contract, birth record, birth plan, transportation waiver, birth consent form and a follow up service survey. If you are interested, the cost is $15.00 + 2.50 shipping. I offered them recently at the DONA conference and have sold a bunch. If anyone is interested in ordering, please contact me at Heart to Heart Doula Services, PO 5044, Poland, OH 44514, (330) 707-9108.

Here is the letter agreement. Feel free to use it or change it any way you want to.

What is a doula?

As a doula, I accompany women in labor to help ensure a safe and satisfying birth experience. I have received education for the doula's role from , RN, LS, Doula, and have the following experience: I have 5 children of my own, all delivered vaginally, I have read several books and pamphlets relating to being a doula and I have attended a 20 hour course preparing as a doula. I have attended six births as a doula and I have the evaluations from those births for you to review from the mothers, doctors and/or nurses. I draw on my knowledge and experience to provide emotional support, physical comfort and, as needed, communication with the staff to make sure that you have the information you need to make informed decisions as they arise in labor. 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 an independent doula. As your doula, I am working for you, not your caregiver or the hospital. I believe that you are in charge of your own birth and that I am the invited guest. I am there to serve you to help you have the type of birth you have envisioned for yourself.

Choosing a doula.

I prefer to meet with you and your partner at least twice 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. At that time, we can discuss fees. My fees are based on a sliding scale. This meeting does not obligate you to use my services, but if you do select me, then I will want to become familiar with your Birth Plan, including your preferences regarding management options and the use of pain medications. I also want to know your own best ways of coping with pain and fatigue and how you and your partner foresee working together.

I will also inform you of times when I am unavailable for labor support. To cover those times, I will arrange one or more back-up doulas whom you may also meet. Of course, you have as much choice over your back-up as your primary doula. We may also decide on other meetings and will certainly want to remain in touch by telephone.

When you are in labor.

I prefer that you call me when you think you are in labor, even if you do not yet need me. I can answer questions and make suggestions over the phone. We will decide if I should come right then or wait for further change. I usually need approximately one hour 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 the birth center. Except for extraordinary circumstances, I or my back-up will remain with you throughout labor and birth.

After Birth.

I usually remain with you for one or two hours after birth, until you are comfortable and your family is ready for quiet time together. I can also help with initial breastfeeding, if necessary.

I am available for phone contact to answer questions about the birth or your baby and would like to get together with you within one to two weeks to see how you are doing, to review the birth, to admire your baby, and to get feedback from you about my role.

What doulas do not do.

As a doula, I do not:

I will make every effort to provide the services described here. Sometimes this is impossible (for example, with a rapid labor). If my failure to attend your birth is due to my error, there will be no charge for my services and I will refund the retaining fee. If it is due to circumstances beyond anyone's control or your failure to call me, I will keep the retaining fee, but there will be no further charges.

Fees.

At the present time, my fee for services described here are $ Half of my fee is due when I am retained and the remaining half is due two weeks prior to your due date. My fees also work on a sliding scale which can be discussed with you at our meeting.

I/We have read this letter describing the doula's services and agree that it reflects the discussion we had with her.

____________________          ____________________