Baby Steps Birth and Labor Support Services Shannon Tuke: Home/Office Phone 520-413-3053, Cell: 520-208-5010
The following is a contract of agreement between _____________________ and Shannon Tuke of BABY STEPS Birth and Labor Support Services (BSBLS) to establish services, obligations and limitations to be consummated.
As of (date)_______________ Shannon commits to accompany ____________________ throughout the labor and birth experience providing continuous emotional and physical support. Shannon will draw from her training, personal experience, knowledge of my/our preferences, her understanding of any traditions, customs and /or rituals important to me/us as explained to her by me/us and her intuition of the moment in providing comfort to me/us. Due to the uncertainty of labor and birth, I/we understand Shannon cannot guarantee every need to be met; however, it is her objective to fulfill each need within her power.
As a Doula, Shannon will:
v Provide any information accessible to her as requested by my/us.
v Provide two (2) prenatal visits to acquire information, discuss preferences, introduce and explore comfort techniques, supply information, to assist in the creation of a Birth Preference Sheet and build a relationship.
v Provide 24hr phone support ending 2 weeks (14 days) following the birth experience, beginning at the signing of t his contract.
v Provide her home phone number, her mobile phone number and email address to ensure the ability to contact her when needed.
v Provide only non-pharmaceutical comfort measures of pain management and encouragement of labor progression, which may include help with breathing techniques, relaxation and positioning.
v Provide one (1) post partum visit to discuss the birth experience, recover any loaned supplies (i.e. books, videos, music, etc...) and congratulate the family.
As a Doula, Shannon will NOT:
v Make any decision regarding any aspect of my/our healthcare.
v Coerce any decisions regarding any aspect of my/our healthcare.
v Provide any medical advice, diagnosis or treatment. Any information or suggestions giving by Shannon should be discussed and evaluated by my/our Care Provider.
v Perform any clinical tasks, such as: drawing blood, monitoring blood pressure, vaginal exams, medicating, monitoring fetal heart tones, or any other medical procedure.
As a Client of BSBLS, I/we will:
v Call Shannon as soon as I/we are aware labor has begun or the need for an emergency induction has been determined necessary.
v Discuss all desires, commitments, fears and concerns with Shannon to assist her in serving me/us.
v Discuss all desires, commitments, fears and concerns with my/our Care Provider.
v Provide a detailed Birth Preference Sheet for Shannon, My/our Care Provider and staff to draw information in assisting my/us in attaining an optimal labor and birth experience.
v Inform all family and friends attending the birth about Shannon and her role in our birth.
v Inform any/our Care Provider about Shannon’s attendance at the birth.
v Take Shannon’s schedule in consideration in choosing a date for a non-emergency labor induction or Cesarean Section birth
v Pay all fees in check or money order form.
As a Client of BSBLS, I/we understand and accept:
v Planning for a birth is like planning a dream house or vacation there are things that may not be available or possible to my/our circumstance.
v I/We are responsible for giving Shannon notice of labor, as defined previously in this contract, if I/we fail to call Shannon upon onset of labor she cannot guarantee her presence and therefore I/we forfeit any moneys refundable due to her absence.
v I/We are responsible for my/our language and actions, as well as those of our guests.
v I/We will conduct myself/ourselves in a mature and respectful manner when speaking to Shannon and/or those who are associated with BSBLS, any abusive, vulgar or demeaning language and/or behavior qualifies as forfeiture of this contract. This will result in the termination of service and the full balance of $500.00 due immediately.
v *I/We have a grace period of 3 weeks (21 days) after the birth to supply Shannon with payment of her service fee. If I/we have not fulfilled this obligation, on the 22nd day following the birth Shannon will seek outside assistance for collection. This will result in a 10% late fee per month of delinquency plus any legal fees incurred in such a pursuit. If arrangements have been made for late payment, a late fee of 10% per month of delinquency will apply without legal pursuit for up to 4 months following the birth.
v Shannon will join us as requested and give continuous care as it pertains to Doula services; therefore, we understand all “False alarms” carry a $25.00 charge for the first 4 hours with an additional $10.00 charge per hour thereafter.
v In the event Shannon misses the birth due to uncontrollable events, such as: unusually quick labor or an “Act of God” after a brief discussion and agreement by both parties she will provide regular post partum care and retain her full fee.
v I/We will supply Shannon with written detailed notice of any dissatisfaction if requesting termination of services and/or refund of fees.
As a Doula, Shannon agrees to:
v Provide me/us with another Doula in the event of an unforeseen event preventing Shannon to attend my/our birth, such as: illness, injury or personal/family emergency. In such and event the Doula attending my/our birth will be paid the remainder of the labor support fee.
v If no one attends my/our birth through no fault of my/our own, I/we will retain all moneys owing pertaining to the birth portioning of the fee.
v If Shannon misses the birth due to uncontrollable events, such as: unusually quick labor or and “Act of God” after a brief discussion with and agreement by both parties she will provide regular post partum care and retain her full fee.
v Conduct herself according to the Code of Ethics and Standards as defined by DONA (Doulas of North America).
The total fee for service is *$500.00 to be paid in two (2) installments: a $300.00 deposit, $50.00 refundable, to retain service, cover charges for prenatal visits and 24 hr phone support; a $200.00 fee for the labor and birth. The first installment is due upon signing of this contract agreement and the balance is to be paid no later than 3 weeks (21 days) subsequent to the birth. I/we may choose to sever this relationship and agreement no later than 2 weeks (14 days) prior to the EDD, Estimated Due Date. The dissolution of this agreement and relationship within the confines stated will result in the return of all fees paid excluding the $50.00 nonrefundable portion; however, any termination on my/our part after said limitations will result in all fees owing.
By signing this agreement I/we acknowledge that I/we have discussed, understand and accept all terms of this contract agreement.
Signatures:
Client: ______________________________ Date:_______________
Partner:______________________________ Date:_______________
Doula: ______________________________ Date:_______________
‑ In the event there is a tragic birth or an unexpected pre-term birth of more than 3 weeks the payment dates will stand using the EDD as the date of birth and all will run accordingly.
* In the case of a special circumstance, other arrangements can be made: reduced fee or a barter agreement to be fulfill with the same time period at Shannon’s discretion.
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