Birth Doula Services Agreement

Birth Doula Services Agreement

Amanda Grabeman Dayton’s Birth Doula’s Philosophy: I believe that a woman’s body has the ability to birth as nature has intended. I believe that women are stronger than they know, and can labor and deliver their baby, or babies, without medical intervention. I will encourage natural childbirth as long as it is physically possible, but I will not interfere with you laboring however you feel is best for you. I am your support, both mentally and physically. I support your decisions, and I will encourage you. I will advise you of risks and benefits to procedures and interventions. I will help facilitate communication between you, your partner (if applicable) and hospital staff to get the best information available. I will not judge you for your decisions or tell you what to do. I am here for you as your support, not your decision maker.

Outlined below is a list of the services I will provide to you, a list of what I cannot provide to your family, an agreement to absolve liability in all situations as well as an outline of my fees for birth doula services. I do offer a 10% military discount, or a discount when paid in full by 36 weeks gestation (only 1 discount may apply).

· 1 initial birth consultation

· 1-2 prenatal meeting(s) as needed or as time will allow

· 1 birth planning session to discuss hospital protocol and birth wishes

· Phone and email support from the time the contract is signed (I will try to respond within 24 hours)

· On-call phone and email support after 36th week of pregnancy begins (I will respond within 2 hours) *I will notify you ahead of time of any engagements that may prevent me from responding within 2 hours

· On-call 24 hours a day starting at week 38 through week 42 for labor

· Phone support for early labor, and in-person support once contractions become more consistent and you feel you need me

· Support during entire labor and delivery

· Attendance after birth for 1 hour to establish bonding and help with anything you need

· Phone and email support for 6 weeks following the birth of baby to help answer any questions or address any concerns

· One follow-up meeting between 1 to 6 weeks after birth of baby (I will collect survey at this point)

Services Amanda Grabeman DOES NOT provide

· Any type of medical care, diagnosis of any illness, prescriptions, cervix checks, fetal monitoring, any type of medical care for you or baby

· Child care or nanny work. Amanda tries to help you gain confidence in your care of your child

· A guarantee of an unmedicated vaginal birth. Doulas provide planning and education for families to make informed decisions. Families must make the decision they feel is best for them.

· Any psychiatric service, counseling or mental health assistance

· Any type of childbirth medical care, such as “catching” of the baby or cutting the cord. Amanda Grabeman is not responsible for the birth outcome

· Assistance for families who choose to have an Unassisted Childbirth or “Freebirth” Unfortunately, this is a liability that limits Amanda Grabeman from being able to attend these births.

By signing this contract, you agree to the following (please initial):

____ I understand that the $100 deposit paid at the first prenatal appointment is non-refundable under any circumstance (with the exception of Amanda Grabeman being unable to attend the birth)

____ I understand that my bill for services must be paid in full by 38 weeks gestation

(unless other arrangements are made ahead of time and noted/signed on the bottom of the contract)

____ I understand that Amanda Grabeman cannot provide any type of medical care to myself and/or my baby and that she cannot be held liable for any birth outcome

____ I understand that if labor appears to be progressing very quickly, I give Amanda Grabeman permission to call 911 and request ambulance assistance. If I am birthing at home, I give Amanda Grabeman permission to call the attending midwife immediately.

____ I understand that Amanda Grabeman cannot attend an Unassisted Childbirth under any circumstance. If it appears that there will be no primary care provided, Amanda Grabeman reserves the right to leave the premises immediately. I will not be entitled to any refund

____ I understand that I am to call Amanda Grabeman when I believe that I am in labor in order for her to attend my birth. She will provide support over the phone until it is decided it would be best for her to go to the patient. Amanda has up to 90 minutes to arrive at my home or the hospital from the time she is requested.

____I understand that if Amanda cannot attend my birth, due to unforeseen circumstances, I am entitled to a full refund, including the deposit

____I understand that Amanda Grabeman reserves the right to leave the premises immediately if she is subjected to any form of abuse, physical or emotional, from myself, my partner or my family/visitors. I will not receive any refund.

I, ______, agree to all of the terms above

Signed (gestating person) ______Date ______

Signed (partner) ______Date ______

Signed (Doula) ______Date ______

Payments and Agreement

· Amanda Grabeman Dayton’s Birth Doula charges a fee of $______for all of the services listed in the contract

· $100 of this fee is a non-refundable deposit, paid upon the first prenatal visit

· The remainder of the fee, $______is due by 38 weeks gestation in order to ensure that Amanda Grabeman will be on-call 24 hours a day from weeks 38 to 42. Without this fee, I will not be guaranteed a birth doula during my labor, as Amanda will not be on call.

I, ______, agree to all of the above payment terms.

Signed (gestating person) ______Date______

Signed (partner) ______Date______

Signed (Doula) ______Date______

For office use only:

Deposit of $100 received ______

Remainder of balance paid ______

Receipt Sent ______

Amanda Grabeman

Dayton’s Birth Doula LLC

(937) 503-6570