Postpartum Doula’s Role  and Obligations

I will meet with you one time prenatally, at mutually agreeable time, at which time we can discuss any questions you might have, and review your postpartum plan which will help organize your thoughts about what is important to you and what role you would like me to take in supporting you and your family. It would be helpful if both you and your partner (if applicable) can be present at these meetings. 

 

I can provide information on options for decisions you may be making in the postpartum period. However, you will be responsible for deciding on a postpartum plan that is best suited to your individual needs and preferences and for discussing any medical aspects with your caregiver, as appropriate.

Limitations of Postpartum 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 informed choices on baby care, medical treatment, or other issues. 

 

I will not perform clinical tasks such as 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. 

Your Obligations

You will create a Postpartum Plan. The framework for the plan is included in this contract. It is understood that circumstances may change unexpectedly, or your needs may change, and so this plan is not rigid. It serves to give us a common understanding of the role you would like me to take in supporting you and your family. I understand that your needs may change, and if that does occur, let me know and we can come to an agreement on a new plan.

 

If your needs change, and the amount of time you need me to spend with you changes considerably, you will notify me as soon as reasonably possible so that I may adjust my schedule. If I am not able to add extra hours to my time with you, I will make every effort to find another postpartum doula who would be able to work with you.

 

You will need to provide a list of emergency contact numbers for family members, family doctor, etc.

Payments and Refunds

Postpartum visits are charged by the hour and there is a three hour minimum for each visit. 

Normally, the full balance is due at our first prenatal appointment or at the time of booking. However, if you are scheduling longer term services, weekly payment arrangements can be made.

 

This requires each week to be paid in full. Full payment must be made in full before I am able to attend our first scheduled postpartum session. 

 

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

 

Cancellations more than two weeks before your due date: 100% refund, less costs of any prenatal visits made. The cost of each prenatal visit for this purpose is $_30_.

 

Cancellation less than one week before your due date: no refund 

Postpartum Plan

The points in this plan are meant to serve as a guideline to indicate the type and extent of support you are looking for. It is not a rigid contract, and may be altered by mutual consent at any time.  

Doula’s schedule

What times would you like postpartum support?

specified number of days per week: ______ days

specified number of hours per day: ______ hours (there is a three hour minimum per visit)

times to be scheduled: 

 

 

How long would you like postpartum support for?

number of days: ______ days

number of weeks: ______ weeks

number of months: ______ months

Doula’s tasks

Please indicate what areas you would like support with. 

Feeding care 

Breastfeeding support _____

Bottlefeeding support_____

Preparing formula_____

If you selected yes to feeding, do you have a feeding schedule? How often would you like me to feed your baby?

___________________________________________

___________________________________________

___________________________________________

 

Infant care

changing diapers_____

(If your child has had a circumcision, I may opt for the parents to do the diaper changes so that they can best care for the surgical site)

take out for a stroll_____

carry / watch baby while you have a nap or attend to another activity _____

other: ___________________________________________

 

Educational support

Please indicate whether you would like information on any of the following: 

feeding_____

sleep habits_____

bathing the baby_____

growth patterns_____

vaccination_____

circumcision_____

jaundice_____

sibling rivalry_____

helping pets adjust_____

other:  ___________________________________________

 

Preparing food

I do not cook meals but will make light snacks upon request. 

 

Snack preferences: 

___________________________________________

___________________________________________

___________________________________________

You must provide your own food, as that is not provided by your doula.

 

Any allergies or dietary restrictions? (please indicate which member of the family these apply to): 

___________________________________________

___________________________________________

___________________________________________

 

Light housework

vacuuming_____

laundry_____

washing dishes_____

cleaning kitchen_____

other: 

___________________________________________

___________________________________________

___________________________________________

Childcare of older children

Names and ages of older children:  

___________________________________________

___________________________________________

___________________________________________

Will they need to have care provided for them while I am there? If so, please explain.

___________________________________________

___________________________________________

___________________________________________

 

Activities suggested or desired (supervision at home, take to park, etc.?): 

___________________________________________

___________________________________________

___________________________________________

 

 

Pet care

Type of pet(s), and name(s) 

___________________________________________

___________________________________________

___________________________________________

 

Care required: 

___________________________________________

___________________________________________

___________________________________________

 

 

Background information

Please indicate anything you think it would be helpful for me to know. For example, anything having to do with your plans for birth, a history of depression, key experiences you recall from after the birth of any older children (either things you are concerned about, would like to do differently, or things you would like to repeat), partner’s work schedule, extended family concerns, concerns about older children – anything you think might be important for me to know so I can know the “big picture” of what you are anticipating after the birth of this child. All information will be held strictly confidential, as indicated in the section on confidentiality, above. If you need more space please continue over the page.

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

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 form carefully and fully understand its meanings and implications.

Postpartum Client's Full Name_______________________________    Date __________

Postpartum Client's Signature _______________________________    Date __________

        Doula's Signature _______________________________    Date __________