Doula’s Role and Obligations

I am independently employed; I work for you, not your doctor, midwife, or hospital.


I will meet with you one time prenatally, at a mutually agreeable time and place. During this visit, we can discuss any questions you might have, and review your birth plan which will help organize your thoughts about what is important to you and help communicate your wishes to your medical caregivers.  It would be helpful if both you and your partner or other birth companion can be present at this meeting. Additional visits can be arranged at an additional hourly charge of $30.  


I can provide information on options for your birth plan. However, you will be responsible for deciding on a birth plan that is best suited to your individual needs and preferences and for discussing the terms with your doctor. 


I will be on call for you 24 hours a day beginning three weeks before your estimated due date (EDD) up until labor begins.  


I will remain with you as long as possible from the time you request me to be with you once labor has begun, until one to two hours after your baby is born, apart from short breaks for meals and rest if needed. Longer breaks, for instance if you first call me in early labor, may be taken as mutually agreed. Some labors can be very long and it is important that I am able to take occasional breaks in order to best assist and care for you.


I will not attend a birth for longer than 24 hours. I am still human and need rest, nourishment, and be able to take care of my family. If your birth goes 24 hours or longer, I must leave. I will follow up with you at your postpartum visit to see how the rest of your birth went. In this event, no refunds will be given. 


I can help you to utilize non-medical support techniques for labor and birth, such as breathing techniques, massage, etc.   


I will maintain a birth log, as circumstances allow, of the events that occur during labor and birth. I will strive to be as accurate as possible in recording the entries but I provide no guarantees in this respect.  I can give you a written record of your birth based on these notes within 2 weeks of the birth of your baby for an additional charge. If you would like a written record, please note that this will take some time away, as I sit and record the events periodically during your labor.

 ___No written record 

___ I would love a written record ($25)

All records I keep are confidential. I will not share these records with any person, except where disclosure is required by law.


I can help you to initiate feeding. I am not a certified lactation consultant, but I can refer you to one if the need arises.  


After the birth, I will reach out to you for your postpartum visit. This can be the day after the birth, the day you return home from hospital, or any other day you prefer. This visit will consist of discussing your birth, how you're feeling, how baby is doing, etc. I will strive to answer any questions or give you a referral to another professional where appropriate.  Additional postnatal visits can be arranged for an additional hourly charge of $30. 

For Doula Care visits, such as postpartum care, these visits can be arranged for $35 an hour with a four hour minimum during the hours of 7am - 7pm. 

For Doula Care visits during the hours of 7pm - 7am, visits can be arranged for $45 an hour with a four hour minimum.

These visits include care for your baby so that you can get some sleep, take a break, and or take care of yourself. This can also include assistance with feeding, caring for mom, light housekeeping, etc. 

(                  )

client initials

Limitations of Doula Practice

I will not make decisions for you. I will provide information that may be helpful for you and/or your partner to make an informed choice. 


I will not perform clinical tasks such as assessing blood pressure, checking the dilation of the cervix, monitoring the fetal heart rate, making any medical diagnosis, administering or prescribing medication, or any other procedure that qualifies as practicing medicine. My role is limited to providing for your physical, emotional, and educational support. 


I will not provide medical advice or advice concerning any alternative therapies. Any information I provide should in no way be construed as medical advice and is not a substitute for medical advice, which only a licensed medical practitioner can provide. It is your responsibility to seek the advice of an appropriately qualified practitioner in case of doubt. 


I will not speak to your medical caregivers on your behalf. I can discuss your concerns with you and provide information on options that may be available and help you with composing questions for you to ask your caregivers, but you or your partner will be responsible for communicating your needs to the medical staff. 


I am not licensed or permitted to deliver your baby or to perform any clinical skills related to the delivery of your baby.  In the event that the baby arrives unexpectedly at home without a licensed medical practitioner in attendance, you or your partner or other attendant will be responsible for catching the baby as he/she is born. However, should your partner or attendant not be available to catch the baby as he/she is born, and if you are unable to do so yourself, then with your consent, I may take on this role.

(                  )

client initials

Your Obligations

You will discuss my attendance with the medical practitioner scheduled to attend your birth.

(If you are planning on having me photograph any part of your labor/birth, you must also discuss this with the medical practitioner who is scheduled to attend your birth and with the hospital in which you are set to deliver at.)


You will call me when you think you may be in labor, even if you are not sure, or as soon as your waters break, so that I may make arrangements to attend your birth. I will provide support over the phone (by call or text) until you decide you would like me to be with you in person. If for any reason you are unable to contact me once labor has begun, you must have someone do so on your behalf. THE INITIAL NOTICE MUST BE GIVEN VIA PHONE CALL. I AM NOT ALWAYS ABLE TO SEE OR HEAR TEXTS, ESPECIALLY IN THE EVENING. 


If you do not, I have no way of knowing that you need me, therefor, I will not be able to make it to your birth. In this case, you will be refunded all but your non-refundable retainer. (non-refundable retainer is 50% of our scheduled fee.)


You will allow me approximately 1.5 hours to reach you from the time you have informed me that you require my presence and I have confirmed notification. Please ensure you have either spoken with me verbally, or received a confirmation from me, that I am aware that you are in labor. If you send a text, and I do not reply, please do not assume that I have received your message. You must continue to contact me until you receive a reply. Again, first contact must be by phone call. If I do not answer, please leave a voicemail and call again. Once this step has been taken, you may text.

If it is between the hours of 8pm and 8am, I am probably sleeping. I do not hear texts when I am asleep. Please call. Have I mentioned that already? 


It is the responsibility of you or your partner to determine when you will leave for the hospital, if you are birthing there. I cannot tell you when to leave.

It is your responsibility to ensure that the necessary arrangements are made to have a medical practitioner present at the birth whether the birth is to be in the hospital or at your home. 


(                  )

client initials



Payments and Refunds

A NON-REFUNDABLE retainer of $_________  is due at the time of booking. The remainder of your balance is due at least four weeks prior to your E.D.D (estimated due date).

If you are booking four weeks or less from your E.D.D, full payment is due at time of booking, and you are still paying the non-refundable retainer of $________.

Payment must be made in full before I am able to be on call for your birth. 


If you decide to cancel this contract, for any reason,  the following will apply:


Full refund less non-refundable retainer of $_________ and costs of any prenatal visits made. The cost of each prenatal visit for this purpose is $_30 per hour__.

Cancellation less than 2 weeks before your due date: no refund 

(                  )

client initials

Elective Cesarean

If, after signing this contract, you plan to have an elective cesarean, and you do not require me to be with you during the procedure (as permitted by your hospital’s policies) and/or immediately before and after the birth of your baby, you will receive a refund, minus your NON-REFUNDABLE retainer.  In this event, you will receive a refund of $________, but such refund shall not be applicable in the case of a non-elective (“emergency”) cesarean.  You must advise me of your decision to schedule a planned cesarean section at least 5 days before your due date for this refund to apply. If you do not advise me of your decision at least 5 days before your due date, you will not receive a refund of any kind. 


You may also choose to have me accompany you to hospital before and/or after your elective cesarean, and to be present with you during the birth, as hospital policy allows, to provide support, information on what to expect, and assistance in making your cesarean birth a positive experience. I can help with bottle/breastfeeding, answer questions about recovery from a cesarean, and let you know what to expect in the first few days afterward. If you choose this service, the amended-service refund is not applicable.

(                  )

client initials

Failure to Provide Service

I will make every effort to provide the services described herein. 


In the case of circumstances beyond anyone’s control, including but not limited to a rapid birth, birth by cesarean, or medical emergency, it may be impossible for me to provide these services. No refund will apply.


If you call in good time to advise that you are in labor, but I do not attend your birth due to an error on my part (such as losing or inadvertently turning off my cellphone, or missing your call), or other commitments, I will refund the total amount paid less the cost of any prenatal care already provided and any postpartum care desired. 


If you are unable to reach me, you are required to leave me a message on my cellphone.


If you fail to call me to advise that you are in labor, for whatever reason, you will not be due a refund of any amounts paid. If there is a remaining balance outstanding, this will still be due no later than 7 days after delivery.

(                  )

client initials

Limitations of Liability

To the fullest extent permitted by applicable laws, my liability for any and all claims, losses, expenses, injuries, or damages related to the performance of services under this contract of whatsoever nature and howsoever arising whether in tort or in contract or otherwise shall be limited to the amount paid by you pursuant to this contract. 


I will not be liable for any direct, indirect, incidental, special, or consequential damages, resulting from the provision or non-provision of services under this contract, even if the possibility of such damages has been specifically advised.


In signing this contract, you agree that you understand and agree with all the points herein. You further agree that you have been given the opportunity to raise any questions that you might have concerning my services and that these questions have been answered to your satisfaction.

(                  )

client initials

I have read this model release form carefully and fully understand its meanings and implications.

Birth Client's Signature _______________________________    Date __________

        Doula's Signature _______________________________    Date __________