Doula Services Agreement
This legally binding agreement is entered into by and between Vanya, CD(DONA), CLC of MaternalSupportCo (hereinafter "Doula") and the expectant parent(s) named herein.
1. Select Your Doula Care Package
Select the care tier that aligns with your perinatal vision (85-90% click-selected):
2. Payment Schedule & Retainer Structure
Select your preferred installment structure:
3. On-Call & Labor Availability Terms
Confirm each operational term (click all to accept):
4. Back-Up Doula Coverage Policy
Select your back-up doula preference:
5. Clinical Disclaimer & Informed Consent
Acknowledge legal scope of practice (click to confirm):
Share any specific birthing traditions, spiritual customs, family desires, or personal boundaries you'd like Vanya to hold during your care:
By checking this box and applying my digital signature below, I verify that I have reviewed, agreed to, and legally authorized all terms of the MaternalSupportCo Doula Services Agreement.
Client Signature
HIPAA & Medical Privacy Authorization
This Medical Privacy & HIPAA Disclosure Authorization permits Vanya / MaternalSupportCo to communicate seamlessly with your healthcare providers to coordinate continuous perinatal advocacy. Review our complete Privacy Policy & Health Data Safeguards for full US and global compliance disclosures.
1. Authorized Healthcare Providers & Clinical Entities
Select all medical providers you authorize Vanya to communicate with (85-90% click-selected):
2. Scope of Protected Health Information (PHI) to Disclose
Select the health information categories authorized for doula coordination:
3. Permitted Communication Channels
Select all authorized methods of communication:
4. Emergency Medical Proxy Delegation
In the unlikely event you are temporarily incapacitated or under general anesthesia:
5. Patient Rights & Privacy Safeguards
Review and confirm your patient rights under federal HIPAA guidelines:
Name specific doctors, clinics, midwives, or specialists you authorize, as well as any individuals or family members to strictly exclude from updates:
By checking this box and applying my digital signature below, I formally execute this HIPAA Privacy Authorization for the purposes of integrated doula care.
Client Signature
Medical History & Prenatal Intake
Please complete your clinical and physiological profile below. To protect your energy, this intake is 85-90% click-selected — simply tap the options that reflect your body and history.
1. Obstetric & Pregnancy Profile
Select your numbers by clicking the chips below:
2. Conception Pathway
Select how this baby was conceived:
3. Prior Delivery Experience
Select all experiences that apply to your prior births (if applicable):
4. Current Pregnancy Health & Physiological Flags
Select any conditions currently diagnosed or experienced:
5. Allergies & Sensitivities Matrix
Click all applicable allergies to protect your safety:
6. Daily Supplements & Nutrition
Select your daily perinatal nutritional support:
7. Emotional Health & Mental Wellness Background
Select any emotional experiences Vanya should sensitively hold:
8. Sensory Preferences During Labor Surges
How does your nervous system process intense sensations?
9. Trauma-Informed Physical Touch Consent Matrix
Click your permission level for each physical doula comfort technique:
| Physical Technique | Permission Level (Click One) |
|---|---|
| Sacral Counter-Pressure: Firm steady palm pressure on lower spine during contractions. |
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| Double Hip Squeeze: Compressing pelvic wings to open pelvic outlet and relieve pressure. |
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| Rebozo Sifting: Using Mexican woven scarf around belly/hips to relax uterine ligaments. |
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| Firm Neck & Shoulder Massage: Releasing tense shoulders and jaw between contractions. |
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| Acupressure (Spleen 6 / Large Intestine 4): Pressing specific acupoints to encourage efficient surges. |
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| Hand Holding & Grounding Anchor: Firm eye contact and holding hands through transition. |
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10. Essential Clinical Logistics
Only essential text details needed:
11. Personal Birth Story, Emotional Anchors & Safe Boundaries
Take a few moments to express your unique journey in your own words:
Share any reflections from previous births, pregnancy losses, surgeries, or conditions you want Vanya to hold with sensitivity:
What worries you most at night? What words, touch, or grounding reminders help bring you back to calm capability?
Any sensitive areas, trigger words, or physical touch guidelines you'd like your doula to know:
I confirm that the physiological, medical, and personal selections above are accurate to the best of my knowledge and reflect my informed preferences for prenatal and birth support.
Client Signature
Birth Preferences & Advocacy Matrix
This advocacy matrix informs your doula, OB/midwife, and L&D nursing team of your values and physiological goals. 85–90% click-based: simply select your preferred options below.
1. Labor Environment & Sensory Sanctuary
Select all environmental conditions desired in your labor room:
2. Labor Comfort & Pain Management Toolkit
Primary non-pharmacological comfort techniques to deploy:
Pharmacological Pain Relief Philosophy:
3. Clinical Procedures & Informed Consent Matrix
Select your default preference for each clinical scenario:
| Clinical Decision Point | Preferred Physiological | Discuss First (BRAIN) | Standard Clinical |
|---|---|---|---|
| Intravenous Line Hydration & venous access |
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| Fetal Monitoring Baby heart rate tracing |
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| Amniotic Sac (Membranes) Breaking waters |
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| Labor Augmentation (Pitocin) Synthetic oxytocin infusion |
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| Vaginal Examinations Cervical dilation checks |
4. Second Stage, Pushing & Perineal Care
5. Gentle Cesarean Birth Contingency
If surgical birth becomes clinically necessary, our family requests:
6. The Sacred Golden Hour & Newborn Hierarchy
First 60–90 minutes following delivery:
Routine Newborn Prophylaxis Preferences:
7. Personal Birth Vision, Affirmations & Support Instructions
Express your unique birth wishes in your own words:
Client Signature
Postpartum Sanctuary Routine
The fourth trimester requires gentle, deliberate holding. Configure your family's postpartum sanctuary routine. 85–90% click-based: simply select your preferred options below.
1. The 7–14 Day "Lying-In" Bubble Philosophy
Choose your family's baseline boundary policy for the first 14 days home:
Visitor Protocol Rules (Select all that apply):
2. Infant Feeding Intentions & Clinical Strategy
Your initial feeding goal (Vanya provides Certified Lactation Counselor support):
3. Daytime Sanctuary Tasks (Doula Priority Queue)
Select all tasks you want prioritized during daytime shifts ($45/hr):
4. Overnight Sleep Sanctuary (10:00 PM – 6:00 AM)
Night shift cadence preference ($50/hr):
Overnight Newborn Management Style:
5. Perinatal Mental Health & Emotional Safety Net
6. Custom Household Rhythms, Nourishment & Postpartum Anxieties
Help Vanya tailor your sanctuary care with your personal notes:
Client Signature
Photography & Media Consent
Birth and postpartum are intimate, sacred life passages. MaternalSupportCo honors your absolute right to digital privacy. 85–90% click-based: select your exact comfort tier and boundaries below.
1. The 4-Tier Privacy Architecture
Select the single privacy level that matches your family's comfort:
2. Permitted Photographic Moments (If Tier 2, 3, or 4 selected)
Select which birth moments you welcome your doula documenting:
3. Absolute Photographic Red Lines (Exclusion Filters)
MaternalSupportCo strictly enforces all selected exclusion parameters:
Describe any specific shots you cherish (e.g., partner holding baby's feet, cord cutting) or exact angles / lighting you wish avoided:
Client Signature
Certificate of Perinatal Support
Elena Sterling & Marcus Sterling are enrolled in continuous on-call support under
Vanya, CD(DONA)
MaternalSupportCo