Contract (including Payment, Cancellation and Refund Policies)
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I have read and agree to the terms and conditions as set out in the Letter of Agreement describing the Doula Services provided by Jennifer Lynn Frye.
(If you have any concerns or questions about the terms outlined in the contract, please contact me before agreeing.)
Name
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First Name
Last Name
What are your preferred pronouns?
Partner's Name (if applicable)
First Name
Last Name
What are their preferred pronouns?
Birthing Individual's Date of Birth
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MM
DD
YYYY
Estimated Due Date
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MM
DD
YYYY
Phone
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(###)
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Additional Phone (if applicable)
(###)
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Email
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Home Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Special instructions for getting to your residence
Please include any special instructions, such as buzzer number, parking tips or details about how to get to your home if you feel it may be helpful.
Is this your first pregnancy?
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Are you taking prenatal education classes?
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If you've registered for, completed, or have already chosen your prenatal classes, please share the name of the class style and the group or teacher who runs the class.
Where do you plan to give birth?
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i.e. Hospital, Birth Center, Home birth- If Hospital, please specify which facility & whether you have registered/toured.
What is (are) the name(s) of your primary prenatal healthcare provider(s)? Please also indicate their profession (midwife, OBGYN, GP) and their clinic name (if applicable)
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Are you seeing any other health care providers?
Accupuncture, TCM, Chiropractor, etc
Please describe your health, in general, pre-pregnancy
To your knowledge, do you have or have you had any of the following:
If Other, please explain further:
Any Allergies or Chronic Illnesses?
Are you taking any medications (prescription or OTC) or vitamins/supplements regularly?
Have you had any childbearing losses?
i.e. abortion, miscarriage, infertility, stillbirth or children placed for adoption
Please tell me about any previous birth(s)
gender, weight, birthdate, name
Please tell me about the birth experience(s)
Vaginal or Cesarean? How did your labor begin? How long did it last? How did you push? What coping techniques did you use? Did you breastfeed/formula feed/both?
Did you experience any complications with the birth(s)?
Complications with the birth itself, immediate health of baby/you, with breastfeeding, etc.
What elements would you like to experience again? What would you like to avoid this time?
How are you feeling about your pregnancy right now?
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Please tell me some of your fears around this birth
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If you can't think of any fears, please tell me what things you may have heard from other parents about their birth that has made you feel badly for them.
Have you read any books on the topics of labor & childbirth or postpartum. If so, which ones?
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Would you like any recommendations?
Who have you chosen to be with you during this birth and what role do you want them to play?
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Additionally, is there anyone you do not want present at this birth?
Do you want or have you written a birth vision/plan?
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Do you have any religious or cultural beliefs/practices that you'd like for me to be aware of?
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How do you imagine I can be most helpful to you during your pregnancy, labor, delivery and postpartum period?
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Ideally, how would you like to welcome your baby?
i.e. Immediate skin-to-skin, delay newborn procedures if possible, allow to nurse immediately, etc.
Are you interested in delayed cord clamping?
Do you plan on breastfeeding?
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If you are planning on breastfeeding, have you begun any preparation? If so, what?
Do you need any additional resources?
If your child is male, are you planning on circumcision?
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In regards to newborn procedures, please check the boxes below that apply to you.
Check those that you plan on getting and any other boxes that apply to you
Any other special concerns or considerations about your child you'd like to discuss?
How often would you like us to be in touch?
Unlimited phone, email, & text come with my service to you, in addition to our face to face meetings.
What is your preferred method of contact from now until labor begins?
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All 3 are available, but which do you prefer?
At this time, when do you imagine wanting me to join you in labor?
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i.e. right when labor starts, at home, at the hospital, in active labor, etc.
How far along in labor would you like to be when we leave for/arrive at your desired place of birth?
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Many women prefer to labor at home as long as possible, but it's a matter of what you're comfortable with.
Do you have anything else you would like to share?
Please mark any items that you would like to discuss during our visits
This allows me to prepare accordingly & provide you with the best information.
