Doula Contract
Doula Bula

After you fill out this request for services, I will contact you to go over details, availability and schedule phone consultation if needed. Deposit is not required until you decide if you'd like to hire Doula Bula for your birth.

Please fill out this form completely in order to prevent any delays in scheduling services.

We respect your right to privacy. All answers provided are held in strictest confidence.
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Email *
Name: *
Phone number: *
Mailing address: *
Estimated due date: *
What number pregnancy is this for you? *
Is this your first time choosing Doula services?
Delivery Hospital or place of birth and care provider? *
Name & Number of partner/support person who may contact me when labor begins: *
Additional support people who will be involved in your birth:
Have you experienced issues related to infertility, hormone imbalance or PCOS? *
Have you experienced a pregnancy loss, miscarriage, or stillbirth? *
If you've had a pregnancy loss, miscarriage, or stillbirth, would you like to talk to me about it? *
Please share some details about previous deliveries: How many weeks were you? Was the delivery induced/augmented? How long did you labor?
In your past deliveries were there any complications? Did you use pain medications? What were your coping techniques?
Is this pregnancy high risk? *
What has influenced your understanding of how birth goes or the choices you are making for this birth? *
Do you have any fears or concerns about this delivery? *
If you have fears or concerns about this delivery, please let me know on a scale from 1-10 how much this fear or concern is affecting you. (1 being very minor, 10 being overwhelming).
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Are you planning to breastfeed? *
Have you had trouble breastfeeding in the past or concerns about breastfeeding this baby? *
How do you feel about being touched while in pain? *
How do you feel about essential oils during labor? *
Would you like your support person/partner involved in your labor? *
Do you have any infectious diseases, such as HIV, Herpes, Lyme, etc? (If yes, please type below) *
Do you have any medical concerns? (If yes, please type below) *
Do you have any food or environmental allergies? (If yes, please type below) *
Would you be interested in Placenta Encapsulation services? *
If pictures are allowed, do you allow Doula Bula to take photos with your device or hers to help capture those special moments for you? *
If you answered yes above, With your permission I may use non intimate photos for advertising, education, peer review or promotional purposes in print or online form. NO Identifying information will be shared under any circumstances. Do you give your permission for photos of your service chosen to be used as described: *
Your responsibilities as a client: (please read and check all boxes to state that you understand and agree to the following) *
Doula Bula is committed to providing you with the services described in this Agreement. She makes every effort to meet your expectations, if she is unable to due to HER own failure a full refund will be made. If she does not make the birth due to NO failure of her own, no refund will be given. *
I agree to the following, as a condition of services: I am paying only for chosen services, which is not clinical, pharmaceutical, or intended to diagnose or treat any disease or condition. I will not hold Doula Bula responsible for my care. Doula Bula will keep this document on file as a record of our agreement. No copies will be released to any third parties and all client information will be kept strictly confidential. *
Briefly explain how you envision your birth: *
Anything else you'd like to share with me?
*Minimum $100 deposit due at booking for Doula services if you are choosing to hire Doula Bula for your birth. NO DEPOSIT NEEDED FOR CONSULTATION. Deposit goes towards total costs and is non-refundable should you choose to no longer utilize Doula Bulas services.* Please send payment to one of the following and comment below which payment method you are choosing- Venmo (friends/family): @DoulaBula CashApp: $DoulaBula (VENMO users: Please do not type "Doula" in the the app when sending payment as it will hold your deposit for a very long time) *If this is a consultation please leave "consultation" in the box below* *
I take no more than two doula clients each month. I will reserve a space for you on my calendar for seven days. Should you choose to hire me, please call/text or send deposit within this period to confirm your decision. After seven days, if I have not received your response or deposit, I will release the space being held for other potential clients. Typing your full name (First and Last) below will serve as your electronic signature agreeing to the terms, conditions, and limitations outlined above. *
How did you hear about Doula Bula? If a website/friend please specify *
Todays date: *
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