BABS

Birth & Baby Services

602-321-0074





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No-cost Birth Doula Application

Please answer all questions, if not sure enter n/a

Check which applies to you*
Have you received prenatal care?*
I want or am open to the following when in labor.*
Do you agree to be an active part of learning about pregnancy, labor and delivery and participating in our prenatal meetings and read/view educational material and videos.**
I agree that if I get a restraining order against any person including the father of the baby, you will notify us right away. You also understand that BABS may not be able to support you if a restraining is in place.***
Smoking*
Alcohol*
Street drugs or prescription drug over use/abuse.*
Homeless*
Birthing client, how does your body display tension? Please check all boxes that appl*
Please check all boxes that you have experienced in the past or currently**
Some hospitals have medical students. Are you open to having medical students participate in your labor/delivery?*
Please check if they apply*
Should you be accepted to receive our servces - * You MUST participate in ALL scheduled in-person and/or video chat meetings. If you cancel a scheduled meeting more than twice, you do not watch assigned videos or read educational material or actively participate in learning and preparing for your upcoming birth, we reserve the right to end our services with you and if nay fees were paid, they are non-refundable.*
Confidentialty/HIPAA Agreement - Check box that applies* The birthing client or parent(s) of the birthing client who is a minor, understand and acknowledge that BABS (Birth and Baby Services) and all doula's associated with BABS (Birth and Baby Services) will have access to the birthing clients medical history, past, present and during labor, after delivery and postpartum. The information obtained may be used for the purpose of doula education and or certification or (re)certification and may be shared with a certification committee and all doulas associated with BABS (Birth and Baby Services). In addition, all information obtained may be used to understand how to best support the birthing client.*
Birth & Baby Services will on occasion take pictures &/or videos on personal cell phones and/or clients cell phones or cameras before, during and after delivery so birthing client &/or spouse/partner can have pictures &/or videos of their birth. All Pictures &/or videos taken are the property of the birthing client &/or spouse/partner and will not be used or shared by BABS – Birth & Baby Services to any person person(s) outside of the client &/or spouse/partner. All pictures or videos taken on doula(s) personal cell phones will be sent to the birthing client &/or spouse/partner's cell phone and then all pictures &/or videos taken will be deleted from the doula(s) personal cell phone. Birthing client & if applicable, spouse/partner. parent of minor agre*
The birthing client does hereby authorize the attending doulas, back up doulas and student doulas to use the TENS unit on birthing client during labor as allowed by the hospital or birth center. The birthing client confirms that they have been shown how the TENS unit works and understands that they can request the use of the TENS unit as long as the medical staff is in agreeance. The TENS unit cannot be used if the birthing client receives an epidural or has any metal in areas the TENS pads would be placed or any open sores. TENS cannot be used by birthing clients with a demand pacemaker, heart disease, epilepsy, in the shower, tube of near water. TENS stands for Transcutaneous Electrical Nerve Stimulation and is applied by means of electro pads which pulses are transmitted across the skin to reduce pain sensation and/or massage based on the TENS unit used. The birthing client will feel a pulsating sensation that may help increase their own pain-relieving chemicals known as endorphins. Birthing client understands that they are using the TENS unit at their own risks and accord and that all BABS – Birth and Baby Service doulas will not be held responsible for any damage the TENS unit can cause the birthing client.*
Do you agree to be an active part of learning about pregnancy, labor and delivery and participating in our prenatal meetings and read/view educational material and videos? Please note that if you cancel or do not show up for a scheduled meeting more than 2 times during the time that the BABS team is working with you, BABS reserves the right to suspend our services due to your lace of involvement. If any fees paid will not be refunded. If fees are due. you will receive a bill for them.*
Do you agree to be an active part of learning about pregnancy, labor and delivery and participating in our prenatal meetings and read/view educational material and videos? Please note that if you cancel or do not show up for a scheduled meeting more than 2 times during the time that the BABS team is working with you, BABS reserves the right to suspend our services due to your lace of involvement. If any fees paid will not be refunded. If fees are due. you will receive a bill for them.*
No guarantee of service* By checking the following box, you agree and understand that you are completing this application for BABS low-cost and no cost birth doula services and that there in no guarantee that services will be provided. You agree and understand that your completed application will be sent to the BABS review committee to determine eligibility for our services based upon the BABS eligibility criteria. Upon determination of eligibility, you will be sent additional forms to complete and will you will be required to provide BABS with copies of asked for documentation to determines not cost or low-cost eligibility.*
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Thank you! Your application has been submitted. We will be in contact with you soon.