Request for Traditional Birth Doula Services

Pregnant Persons Full Name

Please give first and last name

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Estimated Due Date

Based on ultrasound or last menstrual period

Hospital Name

We do not provide services for home births

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OB/Midwife Name

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Labor Partner/support person Name

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Home Address

Please include city

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Zip Code

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Phone Number 1

xxx-xxx-xxxx format

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Phone Number 2

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Email address

this will be the first line of contact. (please check your spam if you are awaiting contact)

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Language spoken other than english

If you prefer a doula who speaks your native language please note it in the special needs section below

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What is your race?

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What # pregnancy is this

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Number of living children

Not including this pregnancy

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What is your age range?

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Health Insurance?

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Any special needs related to this pregnancy?

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Please share any additional ways in which you consider yourself part of a vulnerable community?

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Private doulas working in the Chicago area charge between $600-$1500 per birth. We ask that you select a workable amount for your family, remembering that this donation helps our organiation to continue to offer this service to other people..

Please indicate the amount below that you would be able to contribute

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What date will you be 38 weeks?

Agreement Between Client and Chicago Volunteer Doulas

What your doula will do for you: •They will assist you in a safe and supported birth. • They will meet with you and your birth partner(s) in advance to get acquainted and talk about your birth. •They will be available by phone for other questions/concerns before and after your birth. • They will meet you at home/hospital when you are in labor and go with you to the hospital staying throughout your labor and birth and for 1-2 hours afterwards. •They will make suggestions for labor progress and encourage you to get information to make decisions. • They will visit you following the birth to see how things are going and to review your birth • After the birth, They will provide information for postpartum recovery, breastfeeding, and baby care. • As your doula, they are working for you, not your caregiver or hospital. •If for any reason they are unable to come or continue as your doula, we will make sure that a back-up doula is called in. What your doula does not do: •They do not perform any medical tasks. They do not function in the role of medical personnel. They do not and cannot make any decisions regarding your medical care on your behalf. • They do not and cannot make any medical judgment or give medical advice requiring the expertise of trained medical personnel. • They do not speak to the staff on your behalf. They will discuss your concerns with you and urge you to speak to the health care staff directly yourself. •They will not drive you and/or your birth partner(s) to the hospital while in labor. •They do not attend births unassisted by health care providers. If a birth becomes unintentionally unassisted, your doula will call 911 or require that you call 911. Client Responsibilities: •You will call your doula when you are in labor as agreed. You will give them as much notice as possible to make it to you in a timely fashion. •You will notify the Program Director if you have concerns about your doula assignment. If you decide not to use your doula, you will let CVD know ASAP so that the doula can help another client. •You will share your birth plan with your care provider and let them know that you will have a doula with you in labor. •Your doulas are available to support you during planned Cesarean Birth. You will let your doula and the Program Director know if you choose not to have them present. You may be able to receive half of your donation deposit back if you decide not to use our services and notify us before 37 weeks. By entering today's date below I acknowledge that I have read the above and understand the doula’s role and my responsibilities.

Who has completed this form?

Pregnant Person
Spouse/Partner
Representative from OB/Midwife office
Other:

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If you are completing this form for someone else please leave your contact information.

Please write your full name and email/phone

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