Contract

    I select the:
    Classic Package ($700)Premium Package ($800)Planned Cesarean Package ($700)


    The following agreement is hereby entered into between Terri Schelkoph, referred to as “I” and the ABOVE NAMED PERSON OR PERSONS, referred to as “you,” with the following conditions understood and accepted by both parties.

    As a birth doula, I provide emotional and physical support to a woman and her partner and/or family during her labor and delivery. I can also facilitate communication with your care provider to ensure that you have the information you need to make informed decisions regarding your baby’s birth. I can provide reassurance and perspective to you and your partner, make suggestions for labor progress, and help with relaxation, massage, positioning and other techniques for your comfort. I am independent and self-employed, and so, I am working for YOU, not your caregiver or place of birth.


    Before Labor


    I will meet with you and your partner twice before labor to become acquainted with you; discuss your priorities and any fears or concerns; present evidence-based information on the risks and benefits of common interventions and procedures used during childbirth; discuss your birth plans; and plan how we might best work together.

    I will also inform you of times when I am unavailable for labor support. To cover those times, I will arrange one or more qualified back-up doulas whom you may also meet.

    We may also decide on other meetings, and will remain in touch by telephone and/or e-mail communication.

    I will be on call for your birth two weeks (14 days) before your due date and two weeks (14 days) after it. If you happen to go into labor before or after this period, I will make every effort to be there.

    If you like, I can also help you write a birth plan based on your needs/wants as communicated to me. I will bring a copy of your birth plan with me to your planned birth place.


    During Labor


    I ask that you call me when you think you are in labor, even if you do not yet need me. This gives me time to clear my calendar for the next 24 hours. I can answer questions and make suggestions over the phone, and we can decide if I should come to you then, or wait for further change. I can meet you at your home or your planned place of birth. I usually need approximately one hour to get to you from the time you ask me to come. Once you call me and let me know you’d like me to begin supporting you, I will make every effort to be there within in one (1) hour. Except for extraordinary circumstances, I will remain with you throughout your labor and birth.


    After Birth


    Circumstances permitting, I will remain with you for one to two hours after the birth. For cesarean births, I may stay longer. I am available to answer questions about the birth or your baby, and I will schedule a postpartum meeting within a few days of the birth to visit you and the baby, review the birth, talk over breastfeeding and baby care and get feedback from you about my role.


    Limitation Of Services


    As a DONA-certified birth doula, I abide by the standards and scope of practice of DONA International. As a doula, I do not:

    1. Perform clinical tasks, such as taking blood pressure, fetal heart checks or vaginal exams. I am there to provide only physical comfort and emotional support and facilitate communication between you, medical staff, and care providers.

    2. Make decisions for you. I will help you get the information you need to make an informed decision.

    3. Speak to medical staff or providers on your behalf. I will discuss your concerns with you and suggest options, as well as encourage you and your partner to voice your opinions, questions and concerns to the staff.

    4. Provide medical advice. I can direct you to resources that might help you answer your questions and make informed decisions on your own. If you have questions or want advice about your care or that of your baby, you should contact your care provider.


    Additional Services


    If you are interested in my other services such as belly casting or lactation education, additional fees will apply.

    If you are interested in placenta encapsulation or postpartum doula services, you will be required to fill out a contract specific to those services.

    I am happy to create a custom doula package for you that includes any and all combinations of the services I provide, including prenatal doula services, birth doula services, postpartum doula services, belly casting, lactation education, placenta encapsulation, additional prenatal or postpartum visits, or any other combination of services that is mutually agreeable to both you and I. All packages must be agreed upon in writing by all parties.


    Extenuating Circumstances


    While it is always smart and helpful to have a plan, births do not always go according to plan.

    If you plan a vaginal delivery and a cesarean is performed after labor has already started, I will continue to provide support during the cesarean surgery (as allowed by hospital and/or doctor policies) as well as immediately after to help with your comfort and breastfeeding. I will also follow-up with you after the birth, as I do with all my clients. My full fee would apply.

    If you and your doctor decide that a planned cesarean is necessary (that is, a cesarean done before your due date and/or before the onset of labor), I will provide support during the cesarean (as allowed by hospital and/or doctor policies) and immediately after, as well as one additional three (3) hour postpartum visit to assist with breastfeeding, cleaning, laundry, baby care, etc. for my full fee.

    If you are having a home birth and need a transfer to the hospital, I will accompany you and continue to provide doula support there, if necessary. I cannot under any circumstances attend a planned home birth without a midwife or other care provider present.

    In the event of a precipitous birth in a location other than your planned birth place (such as home or a vehicle) when a care provider is not present, I will provide only emotional and mental support as outlined above.


    Failure to Provide Services


    I will make every effort to provide the services described here. If my failure to attend your birth is due to my error or other circumstances such as extreme illness, family emergency, act of nature, or hospital or birth center policies, there will be no charge for my services and I will refund the fee, minus the $200 deposit.

    If my failure to attend your birth is due to an error on your part (failing to call me, for example) I will retain the $200 deposit and we can decide together whether you would like me to come for one or more postpartum visits and what fee should apply if so.

    If my failure to attend your birth is due to a rapid labor (baby is born less than one hour after you call me and ask me to come), I will provide an additional 3 hours of postpartum support at no cost once you leave the hospital or birth center. This can include assistance with breastfeeding, laundry, cleaning, baby care, etc. My full fee applies.

    I reserve the right to call in a backup doula if your labor should last over 24 hours, but will make every effort to remain with you through the entire duration.

    Any other circumstances out of my control that result in my absence at your birth or your voluntary termination of this contract will be addressed on a case-by-case basis, and may or may not result in a partial or full refund.


    Back Up Doula


    In the event that I cannot attend your birth, a back up doula will attend. I reserve the right to choose the back up doula but I am open to a back up doula of your choosing, as well. I will make my best attempt to choose a backup that has similar training as myself and is a good “fit” for your special circumstances and desires for your birth process.

    You will have the contact information of the backup doula in the case that I am unreachable or have become unavailable when you go into labor.

    You are able to meet with, speak with, or otherwise communicate with the back up doula if you so desire. You can do so on your own at a time that is mutually agreeable for you and the back up doula or I can facilitate a meeting between you, the backup and myself, usually at the second prenatal meeting.

    If neither myself or a back up doula attend your birth, I will retain the $200 deposit and the rest of the fee will be fully refunded.


    Release and Confidentiality


    I will ask you to also sign a release form giving me leave to take notes about you and your birth, including personal information about yourself and your child(ren). This information may be shared with my certifying organization, DONA.

    Signing this contract also gives me permission to discuss your pregnancy and birth with other birth professionals in both formal and informal settings. I will never use your name, your child’s name, the date you gave birth or any other identifying information.


    Responsibility of Client


    I ask that you inform me of any pregnancy-related or other health complications or conditions you may have, as well as any other special circumstances you might have or require. I also ask that you keep me abreast of what happens at your prenatal appointments from 36 weeks forward (if your cervix is dilated, any tests or procedures you might experience, anything your care provider seems concerned about, etc). Text, email and phone are all fine for contact.

    I also request that you inform your care provider that you have hired a doula.

    If for any reason you decide not to have me at your birth after you have signed this contract, I ask that you let me know as soon as possible.


    Fees


    My total fee is $700 for the Classic Package, $800 for the Premium Package, and $700 for the Planned Cesarean Package.

    For the services described here, to be paid as follows:

    $200 as a non-refundable deposit, due when this contract is signed:

    The balance of your chosen plan due by the 37th week of your pregnancy.

    I accept cash or check (made out to “Doula Mama”). You can also make your

    $200 Deposit with a Credit Card

    .

    If you plan to use cash or check, please

    contact me via email

    .

    If alternative means of payment, such as barter, sliding scale, or a payment plan are being used, they must be agreed upon in writing by you and I prior to the signing of this contract.


    Liability


    In entering a contract for Doula (Labor Support) Services with Doula Mama I/We hereby acknowledge that during the performance period of this contract, services may be provided to me/us in my/our home, traveling to a medical facility, and/or hospital. I/We understand that Doula Mama has a limited role pursuant to the description of tasks outlined in the above-referenced contract wherever services are provided to me/us.

    Doula Mama has not represented to me/us that contracting for services guarantees in any way a risk-free or emergency-free labor and birth experience. I/We understand that my/our doula(s) does not make medical decisions on my/our behalf, to include the decision when to seek medical care at a hospital when labor support services are provided in my/our home. When services are performed in a medical facility, I/we acknowledge that Doula Mama is not responsible for the performance of clinical tasks to include medical decisions regarding the inclusion or
    exclusion of treatments available to me/us and my/our baby.

    Now, therefore, in consideration of the above acknowledgements, I/we (both jointly and separately) on behalf of myself, ourselves, my/our heirs, administrators, personal representatives, executors, and assigns to RELEASE AND FOREVER DISCHARGE Doula Mama from all damages or causes of actions, either at law or in equity, which I/we may have or acquire or which may accrue to me/us, my/our heirs, administrators, personal representatives, executors or assigns as a result of using the doula services of Doula Mama. I/We intend this to be a COMPLETE RELEASE AND DISCHARGE them from all liability whatsoever.

    I/We have read all statements contained herein and I/we fully realize that I/we are signing a
    COMPLETE RELEASE AND BAR to any claims which I/we have or believe I/we have resulting from our contract for doula services.


    I/We have read this contract describing the doula’s services and agree to enter into a client-doula relationship for pregnancy and birth.

    Please draw your signature(s) in the following box:

    Your Signature:

    Your Partner's Signature

    Today's Date: