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Mailing Address:
The Valley Hospital
223 N. Van Dien Avenue
Ridgewood, NJ 07450
Doula Consent Form

The Valley Labor Support Doula Agreement
   

You (hereinafter “Client”) have indicated that you would like to participate in The Valley Hospital’s Doula Program. This Labor Support Doula Agreement (the “Agreement”) sets forth the services that The Valley Hospital Doula (“Doula”) will provide, as well as your responsibilities as a Client.

  1. Services to Be Provided By the Doula 
    During Pregnancy
    • The Doula will contact the Client and schedule a one hour consultation to discuss the Client’s birth preferences at least one month prior to her due date. This meeting may either take place via telephone or in person at The Valley Hospital, Kraft Center, 15 Essex Road, Paramus, New Jersey 07652.
    • The Doula will provide the Client with her contact information and will speak with the Client via telephone on an occasional basis, if necessary.
    During Labor
    • Most of the time, the Doula will come to the hospital once the Client has been admitted, assessed, and a determination has been made that the Client is in active labor. The Doula will come before the Client is in active labor, if the Client telephones and advises that she is uncomfortable and in need of additional support.
    • The Doula that is assigned to the Client will make every effort to be at the Client’s delivery and the assigned Doula will be on call once the Client reaches the 37th week of her pregnancy. In the unlikely event the Doula is unable to attend the delivery, the Doula will make every effort to arrange for a substitute Doula to attend. However, if a Client goes into labor prior to the 37th week of her pregnancy, it is not guaranteed that a Doula will be available.
    • Under the supervision of an RN, the Doula will perform the following services:
      • Provide physical, emotional, and informational support and encouragement.
      • Assist with breathing, relaxation, movement, and positioning, as well as other comfort care.
      • Assist with communication and provide emotional reassurance and comfort.
      • Remain with the Client if she is in the shower/tub.
      • Support the Client’s partner (if applicable) and encourage his/her participation in the birth experience at his/her own comfort level.
    After the Birth
    • The Doula will continue to provide comfort and support during the early post-partum period for a maximum of two hours. Specifically, the Doula may assist the Client with breastfeeding, facilitate mother/baby bonding, and/or help the Client become comfortable in her post-partum room.
    • Within a week of Client’s delivery, the Doula will contact Client via telephone to check in with the Client and see how she is doing.
    Services that the Doula Does Not Provide
    • The Doula will not perform any clinical or medical tasks or procedures.
    • The Doula will not make decisions for the Client.
    • The Doula can only provide the above described services at The Valley Hospital. The Doula will not be able to provide these services, if it becomes necessary for the Client to deliver somewhere other than at The Valley Hospital.
    • The Doula will discuss the Client’s birth preferences with her, but she cannot guarantee that the birth will go as planned.
  2. Obligations of Client
    • The Client must inform her physician that a Doula will be present during labor.
    • The Client must contact the Doula by telephone (and not by text message, e-mail, or any other means) when she thinks she is in labor. If the Doula does not answer the telephone, then the Client should leave a telephone message. The Doula will not come to the hospital at this time, but contacting the Doula right away will insure he/she has adequate time to get to the hospital, when necessary.
    • The Client must telephone the Doula again once she has been admitted, assessed, and a determination has been made that she is in active labor. The Client may telephone the Doula again before she is in active labor and request that the Doula come to the hospital, if the Client is uncomfortable and in need of additional support.
    • The Client’s physician or nurse, in his or her sole discretion, may determine that the Doula may not be present under certain circumstances. If such a determination is made, the Client and the Doula must comply with that decision.
  3. Fees
    • The fee for the services described in this Agreement is $750. This fee must be paid to The Valley Hospital’s Family Education Department and is non-refundable, other than as described below.
    • The full $750 fee is only refundable if the Client contacts The Valley Hospital’s Center for Family Education Department and cancels this Agreement before the initial one hour consultation takes place.
    • Once the initial one hour consultation has taken place, the Client may receive a refund of $700 in the following circumstances:
      • Client contacts The Valley Hospital’s Center for Family Education Department and cancels this Agreement no later than two weeks prior to her due date.
      • The Client meets her above described obligations, but the Doula (or a substitute Doula) is unable to attend Client’s delivery.
      • It becomes necessary for the Client to deliver somewhere other than at The Valley Hospital.

By signing below I indicate that I have read and understand the above information, I want to hire a Doula to perform the services described herein, and I will comply with the terms and conditions set forth in this Agreement.

E-Signature *:
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