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Parents with Newborn Baby
Community Postpartum Doula Client Agreement Form

I have read the Community Postpartum Doula Client Agreement and know I can expect the following from my Birthing Gently doula:

  • Phone/text/email (8am-10pm) support during PP contracted term specified with doula

  • Emotional support and guidance- Supporting the family emotionally through the adjustments that occur in the immediate postpartum period.

  • Helping to identify other areas of support that are needed throughout the immediate postpartum period and provide specific referrals.

  • Newborn Feeding Support - Breast feeding/Bottle (formula) feeding support. Assistance choosing and using breast pumps.

  • Newborn care suggestions and guidance -Instruction in bathing, diapering, dressing, swaddling, and soothing techniques.

  • Nutrition - Preparing light meals and snacks for the family as needed. Grocery Shopping. Assist in meal planning and shopping list preparation. Shop for groceries (funds to be provided in advance by client).

  • Light housekeeping: i.e. Folding clean clothes, emptying dishwasher, general straightening up, cleaning and disinfecting all frequently touched surfaces in the home

Scope of Practice

It is not a Postpartum Doula’s role to make any type of medical diagnosis. A Postpartum Doula cannot administer any medical treatment of any kind. A Postpartum Doula can help family to find appropriate outside support and service.

I have read the Community Postpartum Doula Client Agreement and agree to provide the following to Birthing Gently doula:

Reporting fever, diarrhea, vomiting, injury, illness or concerns

  • If you or any household member has a fever of 101.0 F or higher, our policy is that he/she must remain free of fever for 24 hours before postpartum doula services can resume.  Area pediatricians agree with this policy. The 24-hour period begins when fever has broken and remains in a normal range.  Diarrhea and vomiting due to illness are highly contagious.  If any household member has diarrhea or vomiting he/she must be free of such for 24 hours before postpartum doula services can resume. Please remember many of our postpartum doulas will be working with other families who are also welcoming a newborn into the home, and often are working with other families besides yours.  This policy is in place to protect your family and the others who are receiving postpartum doula services. Please note that the same policy applies to the doula in the event she is ill, and we will make every effort to find back up or resume services as quickly as possible.

  • If any children in the household have had a recent injury or illness, we ask that this be reported to the postpartum doula. This allows the postpartum doula to take necessary precautions when caring for any child within the household.


Missed Visit Policy

Our doulas do their best to arrive on time for scheduled visits (15min grace period for traffic, weather, and any other unforeseen delays). If they are unable to attend a scheduled visit for any reason, they will contact you as soon as possible. If you are unable to have a scheduled visit, please contact your doula at least 24 hours in advance.  If your doula has a scheduled visit and arrives to find you are not at home, your doula will wait 15 minutes for you to arrive.

Release From Liability


In entering a commitment for Birth Doula service, I acknowledge that during the performance period of this commitment, services may be provided to me in my home, traveling to a medical facility and hospital. I understand that the aforementioned Birth Doula has a limited role pursuant to the descriptions of tasks outlined in the above-referenced commitment, wherever services are provided to me. The aforementioned Birth Doula has not represented to me that their commitment to services guarantees in any way a risk-free, emergency-free labor and birth experience. I understand that my Birth Doula does not make medical or nursing decisions on my behalf, including the decision when to seek medical care at a hospital or when labor support services are provided in my home. When services are provided in a medical facility, I acknowledge that my Birth Doula is not responsible for the performance of clinical tasks to include medical or nursing decisions regarding the inclusion or exclusion of treatments available to me, and my baby. Now, in consideration of the above acknowledgments, I on behalf of myself, ourselves, my heirs, administrators, personal representatives, executors, and assigns to release and forever discharge my Birth Doula from all damages or causes of action, either law or in equity, which I have or acquire or which may accrue to me, my administrators, personal representatives, executors or assigns as a result of using the Birth Doula services of my aforementioned doula, I intend this to be a complete release and discharge her from all liability whatsoever.

Thank you! We will be in touch shortly!

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