Reserve your Due Date Birthing Person’s Name * First Name Last Name Pronouns * she/her they/them he/him other If other, please list pronouns below Phone Number * (###) ### #### Email * Today’s Date * MM DD YYYY Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Estimated Due Date * MM DD YYYY Desired Services * Envision Birth Birth Care Virtual Care Additional Visits Preferred Doula We are a collective of three incredible doulas, with that being said, if you have a preferred doula for your birth, please specify below. No Preference Morgan Shipp Kalli Chason Support Person(s) Name(s) and Phone Number(s) Place of Delivery (if different from home address) Address 1 Address 2 City State/Province Zip/Postal Code Country Anything Additional I Need to Know Amount Intended to Pay * At Breathe, we offer a sliding scale as well as payment plans, please specifiy below what you intend to pay upon booking and we will invoice you accordingly. Birth Doula Care $1100 Sibling Doula Care $650 Pay it Forward Amount Envision Your Birth $200 Additional Prenatal/Postpartum Visit $50 Virtual Doula Care $450 First 48 Photography $450 If you selected an "Other" amount, please specify what you intend to pay: Breathe Birth Care Doula Contract We the birther and partner, have discussed and reviewed our wishes and plans for the birth of this child with the doula. After this discussion and review the parties agree as follows: 1. The Prenatal Visit -The doula will provide two visits at least an hour long prior to the birth at which the parties shall discuss a proposed birth plan that reflects the needs and desires of the birther and partner. 2. The Doula -The Doula works for the birther and partner if applicable. -The Doula will support the decisions of the birth giver and partner within the limits of the doula’s expertise. -The Doula will articulate and explain all available options and birth plan choices during the birth plan session. -The Doula will remain with the birther once active labor has begun or earlier as requested by the birther or on behalf of partner. -The Doula cannot speak for or in behalf of the birther and partner in their treatment or care choices. -The Doula will not perform any medical procedures or make decisions regarding medical care for the birther and/or baby. -The Doula will be on call 24 hours a day starting at 38 weeks. -The Doula that is contracted will attend the birth. If the unlikely case that Doula can’t attend, the backup Doula will attend. -The Doula shall strive to create a calm and peaceful environment within the circumstances allowed by the location. -The Doula will remain with the birther until at least 1 to 2 hours after the birth of the baby. -The Doula will provide 2 postpartum visits to the birther a day or two after birth and one two weeks postpartum to answer any and all questions regarding the birth and care of the newborn or about the birther. Additional postpartum visits or services can be arranged if that is desired. 3. Birther and Partner -The birther agrees to contact the Doula at the onset of labor. The birther will advise where the Doula should report to begin the labor support. The Doula will report within 2 hours of the birther’s request. 4. Fees for Services -The fee for labor support is $_________. This payment amount includes 2 prenatal visits, 2 postpartum followup visits, unlimited phone support and face to face labor support. The client shall pay a $_________ deposit at the signing of the contract. The remaining $_________ is due at 38 weeks gestation. Please note that the deposit is non-refundable. -At the signing of this contract it is assumed we cannot anticipate the type of labor and birth you are going to have. As a business, we can only contract with a small number of clients in any particular time frame (for fear of missing someone’s birth and not meeting their needs.) We cannot fill our calendar and then change fees according to how births turn out. We are as committed to short laboring clients as we are to long laboring clients, and have been considered a tremendous asset to families that are in need of a cesarean section as recovery, bonding and breastfeeding can be challenging in this case. -Should the birther or partner fail to notify the Doula 2 hours prior to the requested report time, and the doula misses the birth, the full fee will be retained by the Doula. -Barring acts of God, the full fee of $__________ will be refunded if the Doula misses the birth of the child as a result of reporting to the birth more than 2 hours after the mother’s request. -We, the undersigned, have read this Labor Support Contract. We accept and agree to the terms and conditions. This contract will be interpreted under the laws of the State of Utah. As your Doula is an independent labor support specialist that is not a medical professional, their maximum liability is limited to the amount paid under this contract. If you have medical questions about you or your baby, please consult with a licensed care provider. -Your Doula may recommend other treatments or service providers. However, please be aware that we are not responsible or liable for these other services and that you should review your patient relationship and expectations with them. -We respect your privacy and will not disclose that you are a client without your express permission. Full Name for Digital Signature * First Name Last Name Today’s Date * MM DD YYYY Thank you! Someone on our team will reach out to you shortly to confirm your booking and invoice. Have a beautiful day! -Breathe Birth Care Thank you!
