Wholly Mama Birth Doula Participation Agreement
What is a Doula?
A doula is a person who is trained to provide information about a healthy pregnancy, help you prepare for birth and parenting and provide support to you and your family before, during and just after birth.

What You Can Expect from a Doula

Prenatal Meetings: The doula can help you prepare for childbirth, talk with you about healthy pregnancy, practice breathing, relaxation and ways to cope during labor. You can decide how often you would like to meet to prepare for labor and get to know each other. A minimum two times is a good idea. Your doula is also available by phone and can connect you with local resources if needed.

Support During Labor and Birth: Your doula will stay with you throughout labor and provide continuous emotional support, giving you and your partner support and encouragement. She can also make suggestions for comfort and coping during labor, breathing and relaxation techniques.

After the Birth: The doula usually stays for a short time after the birth. Your Doula will also visit you at home after you are settled in with your new baby to answer any questions about things like breastfeeding, baby care, and to talk about your birth.

What Doulas Do NOT Do
Doulas DO NOT do medical tasks like checking blood pressure, fetal heart rate, or check your cervix for dilation/labor. They don’t speak for you when decisions need to be made. They do not talk to other organizations or agencies about you unless you give permission. They don’t make medical choices. Decisions are the responsibility of you and your partner. Doulas take no personal or professional responsibility for the outcome of the birth.

What Doulas Can Do
Doulas CAN offer suggestions and give you choices. The doula can help you understand typical labor as well as understand your own individual birth experience. They can help you get the information that you need to make informed decisions about the birth of your baby.

What is Your Responsibility as a Client?
We look forward to working with you! Our doulas are passionate about supporting our clients through pregnancy and birth. Please remember, doulas are trained professionals who makes an enormous commitment to be available to you. We ask that in turn, you honor our doula’s commitment to you, and that you are respectful of her time. Please arrive at your scheduled meetings in a timely manner, cancel if you are unable to attend, respond to communication within a reasonable time frame and inform your doula as soon as possible if your contact information changes. Communication is key. Talk to you doula, get to know them allow them to get to know you. The more they know about you, your history, and your health, the better they can assist you through your pregnancy and birth.

The following agreements are separate from and in addition to a written contract to be completed prior to or at your first prenatal visit. The written contract and payment confirm your doula's commitment to attending your labor and birth.
Email address *
Participation Agreement *
By typing your name below, you agree to answer to all the client responsibilities outlined in the previous above. You also agree to answer questions after your birth about having a doula. This might include a phone call or filling out an evaluation form. The answers you give will be kept confidential and will be used to make the program even better. We are confident that doulas can help improve birth experiences, therefore other agencies may want to look at the results and the benefits of having a doula. Your name, address and phone number will never be used. While our doulas are passionate about supporting families, please remember that doula work is also their livelihood, and how they support themselves and their families. By signing up with a doula you are making a commitment to call your doula when you are in labor, and that your intention is for your doula to be present at your birth.Finally, by participating in our program, you give your doula permission to bill you (payment expected prior to first prenatal visit) or permission to bill your insurance company on your behalf. If you Agree, please type your name below.
Your answer
Photographic Release of Liability
For Wholly Mama publications, brochures, conference exhibits, website, social media, or articles for outside publication. I ACKNOWLEDGE AND CONSENT to the publication and/or display of any photographs taken of me and/or my baby by Wholly Mama for publications and brochures, Wholly Mama’s website and social media outlets, Wholly Mama conference exhibits, and/or Wholly Mama articles for outside publication. I understand that by my consent, any photograph(s) in which I/we appear may be displayed at national, regional or state/provincial/area conferences, and/or may be transmitted with official Wholly Mama articles for outside publication. Also by being so transmitted, they may be susceptible to being copied, otherwise used, and perhaps altered. I ACKNOWLEDGE that Wholly Mama is not liable to me or my heirs for any misuse of alteration of my/our photograph(s) by others. Further, I understand that if I decide to revoke my consent for publication and/or display of my/our photographs (or photographs of my baby), I must do so IN WRITING VIA CERTIFIED MAIL, to the following address: Wholly Mama Birth Doula, 927 Sheridan Ave N, Minneapolis, MN 55411. If you Agree, please type your name below.
Your answer
Release of Information *
The undersigned gives permission to Wholly Mama and its contracted doulas to share information regarding my care with other providers involved ie: public health nurses, care providers, etc. If you Agree, please type your name below.
Your answer
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.