Forms

Client Intake Form
Please complete this form prior to our first meeting, so I can better understand your needs and expectations of my role as your doula.

Anonymous Evaluation of Doula Services Form
Thank you for choosing me as your doula.  I am committed to improving my service to moms and their growing family and appreciate constructive feedback.  Please complete this evaluation form within three months of birth.  The form is anonymous, your personal information is not collected.

Testimonial Submission Form
Positive birth stories are important in empowering mothers and families with hope and inspiration.  Please consider sharing your birth experience.  Thank you for allowing me to be a part of your growing family.

Client Consent-HIPAA Release Form
Increasingly, DONA International has become aware of instances where doulas were not allowed in their clients’ rooms for exams or the taking of vital signs and were not allowed to be with their clients during triage, citing Health Insurance Portability and Accountability Act (HIPAA) regulations.  These forms are designed to prevent this, as well as protect the client’s confidentiality, upholding DONA International’s Standards of Practice and Code of Ethics.  The first two pages explains the Client Consent and Confidentiality Release Form and the following pages provide examples of notes that the doula will be completing for DONA birth doula certification.