Birth Doula Contract Form Copy and Download Estimated Due Date or Baby's Birthdate *_________________________________ Name * First_______________________________________________________ Last_____________________________________________________________ Address *_________________________________________________________ Line 1 ____________________________________________________________ Line 2____________________________________________________________ City _____________________________________________________________ State_______ Zip Code __________Country _____________________________ Home Phone Number _______________________________________________ Cell Phone Number _________________________________________________ Email ____________________________________________________________ HOW WOULD YOU PREFER TO COMMUNICATE? Occupation _______________________________________________________ Time Off? _______________________________________________________ If yes, how much time? _______________________________________________ Do you have a Partner?_______________________________________________ Partner's Name ____________________________________________________ Partner's Cell Phone _________________________________________________ Will your partner be taking time off work? ________________________________ If yes, how much time will your partner take off? ___________________________ Gender(s) of baby if known: *_________________________________________ Midwife or OB/GYN Name * First_______________________________________ Last_____________________________________________________________ Midwife or OB/GYN Phone Number *____________________________________ Planned Birth Location? *_____________________________________________ Back up hospital if planning a home birth *________________________________ Pediatrician's name First/Last _________________________________________ Pediatrician's Phone Number *_________________________________________ Have you taken a childbirth class? *_____________________________________ If yes, what childbirth course and when. *_________________________________ Are you planning to breast or bottle-feed? *_______________________________ Do you have other children? *__________________________________________ Will they be attending the birth?________________________________________ If yes, what are their names and ages? *__________________________________ ________________________________________________________________ Please briefly describe the births and postpartum experiences of your other children if applicable.... _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Is there anything in your medical or emotional history you would like to share with me? _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Have you experienced any complications with your pregnancy? _________________________________________________________________ _________________________________________________________________ Do you have religious preferences? _________________________________________________________________ Do you have any fears about your upcoming birth? _________________________________________________________________ _________________________________________________________________ Please mark any of the following items that you would like included in the contract: Breast Feeding Information (Included with birth pkg) Cloth Diapering________ Babywearing Information_______ Nutrition/Exercise for Pregnancy__________ Photography before, during and /or after the birth. __________ Personal Childbirth Birth Instruction__________ Paintings or Jewelry Making (Create Heirlooms /early stages of labor________ Music to Birth by_____________ Painted Belly Casting____________ Baby Swaddling Instruction __________ Your Written Birth Story (Included in basic package)___________ Video Possible_____________ Placenta Encapsulation____________
TOTAL PRICE _________________________ I agree to pay 50% of our agreed upon price upon the signing of this contract and the final portion to be paid within 7 days of delivery. CLIANT SIGNATURE___________________________Date________________
