Postnatal Doula Booking Form

Mum's Name *

First Name

Last Name

Partner's Name (if applicable) *

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

Other - please leave me a note at the end of the form

None

Payment Method *

Cash is always preferred! .x

Cash

Bank Transfer (BSB: 242-200 Acct: 430973370)

PayPal (3% surcharge)

Credit Card (3% surcharge)

Afterpay (3% surcharge)

Automated Payment Plan (3% surcharge)

Services *

Let's tailor your package.

Ultimate Postnatal Support Package ($2650)

Comprehensive Postnatal Support ($1450)

Basic Postnatal Support ($750)

Birth Debrief - 1.5hrs ($150)

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

Baby Care Skills Workshop - 1.5hrs ($150)

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

6 x 75min Postnatal Recovery Massages ($500)

3 x 75min Postnatal Recovery Massages ($300)

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

Sleep Doula Package ($650)

Customised Sleep Strategy ($420)

Mini Sleep Strategy ($260)

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)

Birth Planning Session - 1.5hrs ($150)

Postnatal Planning Session - 1.5hrs ($150)

Labour Strategies Workshop - 2hrs ($200)

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

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

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 minus those for services already rendered will be refunded. The breakdown of fees for the purposes of a refund are; antenatal session = 15%, each week on call = 10%, birth support = 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 a caesarean occur, 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 50% deposit is required to secure your booking and is non-refundable. Full upfront payment is appreciated however payment plans are available, provided full payment is complete before 37 weeks gestation. Should a cancellation occur before the on-call period commences, you will be refunded everything paid over the deposit amount. 9. Full payment of classes, workshops, 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 classes, workshops, 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 as an breastfeeding mother, occasional pumping or feeding of her child may be required. POSTPARTUM DOULA Scope of Service, Limitations and Fees A postpartum doula provides evidenced based information on things such as infant feeding, emotional and physical recovery from birth, mother–baby bonding, infant soothing, and basic newborn care. A postpartum doula is there to help a new family in those first days and weeks after bringing home a new baby. A postpartum doula is primarily engaged to: - Support you in parenting to your values and healing from the delivery of your baby - Provide information about support services e.g. Breastfeeding Australia, Karitane - Offer reassurance and perspective - Encourage and facilitate self-care - Become familiar with your plans for nursing and sleeping and support you in your decisions - Be available to you at our agreed schedule; however please understand that I am on call for birthing families and if they need urgent support - either by phone or in person – I must prioritise the birthing families that I am 'on call' for. A postnatal doula can also assist with: - Grocery shopping and preparing nutritious meals - Infant massage education - Teaching you to read your babies cues - Accompanying you to appointments with baby - Light household duties - Secondary newborn care - Answering questions and help sourcing referral services - Guided relaxation, visualisation and meditation - Remedial Massage (additional charge to bring table) - Private Yoga Practice to help support your recovering body A doula does not have any clinical responsibility, as such I will not: - Give medical advice, recommend medical treatment, or diagnose - Replace a trained lactation consultant 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