Birth Doula Application

Pregnant Person's Name *

First Name

Last Name

Partner's Name *

First Name

Last Name

In the last 6 months have you been tested for: *

Please select all that apply

Hepatitis B

Hepatitis C

HIV/AIDS

none

Were all tests negative? *

Yes

No

Pregnancy-related complications or special circumstances *

Group B strep positive

Rhesus negative

Placenta praevia

VBAC

Malpresentation

Gestational diabetes

Advanced maternal age

IVF/IUI

None

Have you written your Birth Plan/Preferences? *

To be able to support you, a birth plan is crucial to be able to show your care providers should questions arise about your preferences. Here is a link to my favourite birth plan kit which demystifies your options: https://nancymcleanblog.files.wordpress.com/2016/10/birth-plan-kit-rethink-birth.pdf

Yes, it's ready!

No, but we will.

Do you want photography/video of labour and birth? *

Yes

No

We're not sure yet

Payment Method *

Cash is always preferred! .x

Cash

Bank Transfer

PayPal (3% surcharge)

Credit Card (3% surcharge)

Services *

Let's tailor your package:

Pregnancy & Labour Doula Support

- Option 1 ($2450)

- Option 2 ($3000)

3 x 75min Pregnancy/Postnatal Massages ($300)

6 x 75min Pregnancy/Postnatal Massages ($500)

Postnatal Doula Support - Ultimate ($2650)

Postnatal Doula Support - Comprehensive ($1450)

Postnatal Doula Support - Basic ($750)

Choosing your Care Provider Session - 1.5hrs ($150)

Extended Birth Planning Session - 1.5hrs ($150)

Couples Labour Strategies Workshop - 2hrs ($200)

Relaxation Massage for Pregnancy Couples Workshop (1.5hrs) ($150)

Intensity of Labour Preparation Couples Course - 3 x 1hr ($300)

Art & Science of Infant Sleep Workshop - 1.5hrs ($150)

Develop a Prenatal/Postnatal Yoga Practice - 3 sessions + personalised home practice ($300)

Baby Care Skills Workshop - 1.5hrs ($150)

Mother & Baby Blessing Planning and Facilitation ($300)

Baby Massage Classes - 3 x 1hr ($300)

Placenta Encapsulation (Raw method) ($250)

Placenta Encapsulation (TCM method) ($270)

Placenta Smoothie ($70)

Placenta DIY Smoothie Training ($40)

Placenta Tincture - w/ encapsulation ($50)

Placenta Tincture - w/out encapsulation ($100)

Placenta Natural Skin Care ($85)

Sleep Doula Package ($650)

Customised Sleep Strategy ($420)

Mini Sleep Strategy ($260)

Body Balancing Workshop (Spinning Babies) ($150)

Reclaiming Birth Ceremony (Trauma Release) - 2hrs ($200)

Terms and Conditions *

1. A Doula does not have any clinical responsibility and will not: - Perform any medical procedure, including taking blood pressure, foetal assessments, vaginal examinations or taking temperature - Give medical advice, recommend medical treatment, or diagnose - Replace a trained lactation consultant. 2. Clients who choose to utilise items the Doula provides - including but not limited to - heat packs and essential oils, take full responsibility for their own health and for researching and using the equipment or remedies available. The Client agrees that the Doula is not liable and does not take responsibility for any results or effects the Client may experience as a result. 3. The Client will be liable for damaged property and/or equipment belonging to the Doula should any equipment become broken and/or damaged whilst in the Client’s care. 4. The Client consents to the attendance of the Doula to the extent necessary to support her through labour and delivery. In the event the Client does not call the Doula, or give the Doula reasonable notice, or the Doula is not permitted by the attending doctor/hospital no refund will be given. 5. The Doula reserves the right to withdraw service at any time due to conflict or personal health or safety concerns - including but not limited to any kind of abuse, passive or second-hand smoke and aggressive pets. If deemed reasonable, the Doula will seek the services of a replacement doula to support the Client. If services are withdrawn by the Doula, all fees less those for services already rendered will be refunded. The breakdown of fees for the purposes of a refund are; antenatal session = 15%, 1 week on call = 10%, birth support and debrief = 30%. 6. The Doula reserves the right to refuse transport of the Client - including any family member - in her personal car due to liability concerns in case of an accident. 7. Should an unexpected caesarean occur before the due date, the Doula will support the Client through that birth experience and help the Client prepare for the best outcome for her, her partner and her baby. 6. The Client agrees to complete a Feedback Form online, answering questions honestly to help provide statistics and testimonials for the Doula. 8. A $1000 deposit is required to secure your booking and is non-refundable except for compassionate circumstances due to miscarriage. Full upfront payment is appreciated however payment plans are available, provided full payment is complete before 37 weeks gestation. Should a change of mind cancellation occur before the on-call period commences, you will be refunded everything paid over the deposit amount minus any services already rendered. 9. Full payment of yoga, massage and postnatal sessions is required before or on the day of service. If prepayment is made by bank transfer, funds must be visible in the receiving account before the service is carried out. 10. Cancellations of yoga, massage and postnatal sessions must be made with a minimum of 48 hours notice otherwise a 50% fee will be charged. 11. A 50% surcharge may be applied for scheduled services required outside of Monday-Friday 10am-6pm if reasonable attempts between the Client and the Doula are not made to find a mutually agreeable time. Public holidays are charged at 100% surcharge. This does not apply to attending your birth. 12. The Doula will be available via phone (voice and video) throughout the Client's early labour and will join the Client to support active labour and delivery. 13. It is the Client's responsibility to stay in close contact and notify the Doula of any sign of labour and when planning to have the Doula join, allow a minimum of 1 hour plus travel time for the Doula to arrange care for her own child and arrive. 14. Please be considerate of the Doula's own health needs. The Doula's role is to prioritise the Client's needs and will not take any incidences of leaving the Client lightly, however health and hygiene matters such as eating, napping and showering may be required. 15. In exceptional circumstances where the Doula is unavailable to attend the Client in labour, every effort will be made for a suitable Doula to attend in a timely manner. This 'backup' Doula will be provided with confidential information about the Client, only to the extent necessary to provide adequate and appropriate care. If a backup doula is not provided, a refund and/or exchange of services will be offered. Important Disclaimer Please note: Doula's do not give medical advice and always recommend you seek advice from a registered health professional. By checking the box below you agree that all the information you have given is correct to the best of your knowledge. You also agree to the Terms and Conditions above.

I have read and understand the Terms and Conditions