Pay By Check Birth Client NA

Birth Client Needs Assessment (NP)

Please Note We Are Full For May & June Due Dates And Cannot Take Clients Due In These Months

First Name

Last Name

Estimated Due Date

Preferred Pronouns

Cell Phone

Birthday

Support Person's Name

Support Person's Phone

Street Address

City

State

Postal / Zip code

Note: $20 mileage fee applies to clients to Kyle, Dripping Springs, Manor, Jonestown, Georgetown, Hutto, Leander, Lago Vista, Lakeway, Elgin, Spicewood, Bee Cave, and other towns not listed that are 15+ miles from Central Austin.

Repeat clent or friends & family?

Doctor/Midwife

Name of Hospital/Birth Center/Home

What number pregnancy is this and number baby?

Sibling(s) & Age(s)

Please list any prenatal testing you've had and the results:

Explain in detail any complications with this pregnancy and any restrictions placed on you by your caregiver, including listing any medications you are currently taking or health history that you think is helpful to share:

Have you taken any childbirth classes? If so, which one(s) (Bradley, Lamaze, hospital, etc.) Please list any other classes you are currently enrolled in (breastfeeding, infant care, infant CPR, etc.)

Who d you plan to assist you in labor? Who will be with you when you give birth?

Explain your ideal birth.

List ways you typically cope with stressful or painful situations. In nervous or painful situations, how does your body typically react?

Do you have any reservations to physical touch to any part of your body due to abuse? If so, please indicate what we need to be sensitive to, please indicate your trigger words.

Have you ever had any type of cervical/vaginal/uterine surgery, including previous cesarean or LEEP procedures, D&C, abortion, or biopsy?

Did you use ferility treatments for this pregnancy (IUI, IVF, egg donation, surrogacy, sperm donor, etc.)? If so, what treatment(s)?

As a high volume, professional group we have a wealth of knowledge and experience with providers while they are in action, supporting you, their client, in the Labor & Delivery room. Are you interested in learning more about our experience with your provider?

Yes

Please select the package you are agreeing to today. If choosing to pay 50% deposit now, final payment is due by 34wks and can be made via invoice or check. HSA cards accepted.

Birth Package: 2 prenatals + labor + post birth - $2288

50% Deposit Birth Package: 2 prenatals + labor + post birth - $1144

Coupon Code:

The following services are available and can be added to your package via invoice or paid for directly through the website (note you'll be invoiced for these options separately): Required

Note: Fees for labor support are as is, regardless of length of labor, whether labor lasts 2 hrs or 24+ hrs. We encourage clients to sign up early in pregnancy in order to get the full benefit of our expertise.

I agree to the terms & conditonsView terms here (or below)

Your Signature

Terms of Service

Confidentiality

Due to current confidentiality regulations all doulas should have a signed release form from their client before taking any notes about them, their labor, birth or postpartum. The best way to be fully compliant would be to get this release signature at the first prenatal visit, or upon first meeting and joining the client. Clients should receive a copy of the form they signed, and the doula should have her copy with her at all times to be able to show that she is indeed complying with the confidentiality regulations if questioned. Confidentiality of medical and personal information obtained during the course of the doula’s work is of the utmost importance. Failure to comply with these confidentiality regulations could result in penalties.
I, _____________(client), give my permission, for my ATX Doulas to take notes about me, including personal information I choose to disclose to her and information regarding my labor, birth and postpartum, as well as any information regarding my child/ren. I realize that this information will be shared with the doula that is providing back up support. I also understand that this information may anonymously be used for the for statistical purposes, and that my ATX Doulas doula may use this information to provide me with a summary for my own personal use.

Services Contract

Parties Involved

We thank you for choosing ATX Doulas for your doula services. The doula who attends your birth will be assigned depending on the 24/7 on-call schedule based on the time you go into labor. Your postpartum doula will be matched for you based on needs, availability, and geography. This contract is an agreement between “client” (please print your name on the client line at the end of this contract) and ATX Doulas (“doula”). The doula will provide labor support for client’s birth, or postpartum support after delivery.

Birth Doula Services

Prenatal Classes

These sessions are used to become acquainted, to explore and discuss your priorities and any fears or concerns, and to plan how we might best work together. One of the prenatal visits will be used to create a birth plan/preferences with you and your support person to determine pain management options and the use of pain medications. We will also want to know your own best ways of coping with pain and fatigue and how you and your support person foresee working together and with the Doula.

Scope of Practice

Doulas are not medical providers and WILL NOT:

Perform clinical tasks, such as blood pressure, fetal heart checks, vaginal exams, or other medical procedures that fall under the legal definition of practicing medicine.
Provide information, dosages, or advice concerning prescription or alternative medication, or medical advice pertaining to you or your baby.
Make decisions for you. Your Doula will help you get the information necessary for you to make an informed decision. Your Doula will also remind you if there is a departure from your pre-prepared birth plan;
Speak to staff on your behalf. Your Doula will discuss your concerns with you and suggest options to you, but you or your partner will speak on your behalf to the clinical staff at all times.

Duration of Labor

Fees for labor support are as is, regardless of length of labor, whether labor lasts 2 hrs or 24+ hrs. Your fee for doula services includes continuous labor support, which is based upon a reasonable expectation of delivery. If, for some unforeseen reason, this labor support continues for a period over twenty-four hours (24 hours), your doula may, at her discretion, arrange for a backup doula to continue the labor services being provided to you in order to ensure that proper attention can be maintained.

Labor Services & When to Call
Doula will accompany client to labor to help ensure a safe and satisfying birth experience. Doula will draw on her knowledge and experience to provide physical, emotional, and informational support to client and client’s partner. As your doula, we are working for client, not for client’s caregiver or the hospital. As soon as client thinks she is in labor, anytime day or night, she will call the ATX Doulas 24/7 phone number at 512.931.4404. Any additional services offered by doula will be demarcated below and explained in addendum.

After Your Birth

Your Doula remains with you for one to two hours after the birth, until you and your family are comfortable. During that time, Your Doula will provide support for your comfort, take photographs of your expanded family, and help you initiate breast/bodyfeeding. Thereafter, Your Doula is available by phone/email to answer any questions regarding the birth of your baby.

Client's Responsibilities

The client is responsible for informing her caregiver that a doula will be present at her birth and ensuring the doula will be allowed to support her; in the event of an unexpected or planned Cesarean birth, the client or their partner will be responsible for requesting to allow the doula into the operating room (OR). A doula supports a Cesarean birth during pre- and post-op and will join the family for the birth if possible. Many hospitals’ policy allows for only one support person at a time in the OR but this can sometimes be overridden, usually by an attending anesthesiologist.

The client is responsible for their own clinical and medical well-being. The client will notify the doula of any pregnancy or non-pregnancy complications should they arise and is responsible for completing the accompanying intake form by providing forthright responses. The client is responsible for making informed decisions and for her own education and research on topics pertaining to her.

Postpartum Doula/Night Nanny Services

Postpartum Doula’s will offer full time support with infant care, breast/bodyfeeding, meal preparation, laundry, light housekeeping, emotional support, home organization, errand runs and safety tips. Postpartum doulas promote time for infant and family bonding while creating a sense of balance and organization during your recovery period. Night Nannies provide full time infant care on the overnight shift so parents can sleep.

Waiver of Liability

By executing this Agreement, you, the undersigned, hereby acknowledge that during the performance period of this contract, services may be provided to you in your home, traveling to a medical facility, hospital, and/or birthing center. Your Doula has not represented to you that contracting for her services guarantees in any way, a risk free or emergency free labor and birth experience. You understand that Your Doula does not make medical or nursing decisions on your behalf, to include the decisions when to seek medical care at a hospital or birthing center when labor support services are provided in your home. When services are performed in your home or a medical facility, you hereby acknowledge that Your Doula is not responsible for the performance of clinical tasks to include medical or nursing decisions regarding the inclusion or exclusion of treatments available to you and your baby. Therefore, in consideration of the above acknowledgments, you (both jointly and separately) on behalf of yourselves, your heirs, administrators, personal representatives, executors, and-assigns do RELEASE AND FOREVER DISCHARGE Your Doula, ATX Doulas, from all damages or causes of action, either at law or in equity, which you may have or acquire or which, may be accrued to you, you heirs, administrators, personal representatives, executors, or assigns as a result of using the doula services provided by Your Doula, ATX Doulas. You hereby intend this to be a COMPLETE RELEASE AND DISCHARGE from all liability whatsoever.

Disclosure of Communicable Diseases

You agree to disclose any communicable diseases that you have so that your doula can take appropriate precautions.

Dispute Resolution

Dispute Resolution: In the event a dispute arises out of or in connection with this Agreement, the parties will attempt to resolve the dispute through friendly consultation. If the dispute is not resolved within a reasonable period of time, then any or all outstanding issues shall be submitted to mediation in accordance with any statutory rules of mediation under Texas law. If mediation is not successful in resolving the entire dispute, any outstanding issues shall be submitted to final and binding arbitration in accordance with the laws of the State of Texas. The arbitrator's award will be final, and judgment may be entered upon it by any court having jurisdiction within the State of Texas. No party to this Agreement shall be entitled to and shall not receive attorney’s fees and/or expenses arising from any such dispute.

Refund Policy

The most current refund policy can be found here.

Payment Agreement

The client agrees to the following payment agreements found here.