DOULA CLIENT AGREEMENT—CRESCENT MOON BIRTH

(PHONE/EMAIL SUPPORT ONLY)

THIS AGREEMENT is made and entered into on the                day of                            , 20         , by and between FULLMOONMAMA a CT limited liability company, hereinafter referred to as the “Doula” or “I,” and                                                                                       , hereinafter referred to as the “Client” or “you.”

 

This is an agreement with FULLMOONMAMA, a CT limited liability company. This agreement is not with LAUREN GOMOLA personally.

 

     1. Scope of Services

As your Doula, I support you prenatally VIA PHONE AND EMAIL to help ensure a safe and satisfying birth experience. I will assist you emotionally, educationally, and mentally.

During pregnancy, I will talk with you during 1 prenatal visit (1 hour long) via ZOOM to discuss your pregnancy, your thoughts and preferences about the birth, your gynecologic history, your knowledge of the birth process and choices in childbirth, your birth preferences (if desired), labor positioning, pain-coping techniques, the role of your spouse/partner and others attending the birth, any questions or concerns you are having, and how we can best work together. At your request, I can provide educational information, resources, and referrals; and I am available from point of hire until , but not including, the birth.

At all times, I work for you—not your physician, midwife, hospital, or birth center; and I provide information and support to you to help you make informed medical decisions.

 

I do not provide the following services: I am not a medical provider. I do not give you medical advice. I do not perform clinical tasks such as blood pressure checks or vaginal exams. I do not diagnose medical conditions. I do not make medical decisions. I do not speak to providers on your behalf. I do not promise or guarantee a risk-free or emergency-free birth. I am not liable for the outcome of the birth.

 

     2. Duties and Responsibilities of Client

You agree that:

  • Contact can be made 24/7 via phone or email. You will receive a response within 12 hours.

  • This contract ends when you are in active labor.

  • You make the decision as to when to leave home (if laboring at home) to go to the hospital or birth center. While I can answer questions and provide input, you are responsible for deciding when to leave.

  

    3. Fee

My fee for these doula services (prenatally phone/email only) to be provided is $300 total. You may pay by cash, check, Venmo or PayPal. Fee is due at sign of contract. 

     4. Refund; Terminating the Agreement

You have the right to terminate this agreement at any time. Payment made under this agreement is subject to the following terms regarding refunds:

Refunds are not provided under the following circumstances: You choose not to have me provide the doula services after signing the agreement.

Your fee will be refunded in full if I am unable to provide services due to circumstances within my control.  Refunds will be issued within 30 days.

 

     5. Certification

I will maintain appropriate doula certification throughout the life of this agreement.

    6. Grievance Policy; Mediation

I always strive to meet or exceed your expectations. If for any reason you are unsatisfied, I encourage you to communicate with me directly so that I may rectify the situation. You may also file a grievance with DONA, Stillbirthday and/or Bebo Mia if for any reason you want to speak privately with another doula regarding your concerns. DONA, Stillbirthday and/or Bebo Mia will do their best to assist you with your concerns and, if necessary, will contact me so that I may have the opportunity to offer a solution. If you are ever unsatisfied with how a grievance is handled, you may elect to solve the disagreement through mediation with a third-party mediator.

 

     7. Release from Liability

You understand that I have a limited role pursuant to the description of services outlined above. You acknowledge and agree that I have not represented to you that contracting for my services guarantees in any way a risk-free or emergency-free labor and birth and/or postpartum experience. You acknowledge and understand that I make medical decisions on your behalf, including but not limited to the decision when to seek medical care at a hospital when labor and birth and/or postpartum support services are provided in your home. When services are performed in a medical facility, you acknowledge and agree that I am not responsible for the performance of clinical tasks including but not limited to medical or nursing decisions regarding the inclusion or exclusion of treatments available to you and your baby.

Now, therefore, in consideration of the above acknowledgements, you (both jointly and  separately), on behalf of yourself, yourselves, and your heirs, administrators, personal representatives, executors, and assigns RELEASE AND FOREVER DISCHARGE me from all damages or causes of actions, either at law or in equity, which you may have or acquire or which may accrue to you or your heirs, administrators, personal representatives, executors, or assigns as a result of using the doula services under the agreement. You intend this to be a COMPLETE RELEASE AND DISCHARGE to me from any and all liability whatsoever.

You acknowledge and agree you have read all statements contained herein and you fully realize that you are signing a COMPLETE RELEASE AND BAR to any claims which you have or believe you have resulting from our agreement for doula services.

     8. Miscellaneous

This agreement constitutes the entire agreement between the parties relating to this subject matter and supersedes all prior or simultaneous representations, discussions, negotiations, and agreements, whether written or oral.

This agreement may be amended or modified only by written agreement of all parties, which shall include handwritten changes to the document in the presence of all parties as long as the handwritten change is initialed by all parties.

This agreement shall be construed in accordance with the laws of the State of CT and the parties hereto agree that venue shall be in Fairfield County, CT.

If any dispute arises between the parties with respect to the matters covered by this Agreement which leads to a proceeding to resolve such dispute, the prevailing party in such proceeding shall be entitled to receive its reasonable attorney fees, expert witness fees, and out‑of‑pocket costs incurred in connection with such proceeding, in addition to any other relief to which it may be entitled.

IN WITNESS WHEREOF, the parties have executed this agreement on date written above.

Your Signature

Partner's signature (If applicable)

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