Agreement to participate in the Los Angeles County Department of Public Health

African American Infant & Maternal Mortality (AAIMM) Initiative

Doula Program

Date: _________ __ Estimated Due Date: _________ _ _ _ _

Mother's Name: _________________________________________ (hereafter known as the “ client”)

Your doula ______________________________________ is a doula with the Los Angeles County
Department of Public Health AAIMM Doula Program.

Doula services outlined below are at no charge/free to you. __________

Client Initials

Doula Obligations

❖ I am an independent contractor which means I will be working for you, not your care
provider or hospital.
❖ I will provide three (3) in-person or virtual prenatal visits that will include birth plan information and
consultation, and three (3) postpartum visits.
❖ I will provide pregnancy and postpartum information and resources to enable you to make informed
choices.
❖ I will provide unlimited email support and phone/text support during business hours (9am- 9pm)
after the signing of our contract until the completion of the postpartum visits.
I will be on call for you 24 hours a day beginning two (2) weeks before your estimated due date (EDD)
until I join you during labor. During this on-call period, I will also provide unlimited (not confined to business
hours) text and phone support, until I am with you during labor.
❖ I will provide early labor support via phone and/or in your home.
❖ I will remain with you once active labor has begun until one to two hours after your baby is born. I
may take short breaks for meals and rest if time allows. In the rare event that labor is very
protracted, I may call my back-up to bring in fresh support for you. I would discuss this with you
before acting. NOTE: Current COVID-19 facility policies may limit the number of support persons
allowed to attend your birth and/or restrict access to individuals who cannot show valid proof of
COVID-19 vaccination, or a current negative COVID-19 test. For current COVID-19 policies,
please inquire with your chosen birthing facility. If I cannot be with you in person, I will provide
virtual support.
❖ I will draw on my knowledge and experience to provide emotional support, physical comfort, and
to help you communicate with the medical staff. I can provide you with reassurance and
perspective, make suggestions to help labor progress and help with relaxation, massage,
positioning, and other non-medical techniques for comfort and coping.
❖ If breastfeeding, I will help you initiate that process.
❖ After the birth of your baby, I will visit you at home or in the hospital, between three to fourteen
days postpartum. I will answer any questions or give you referrals to appropriate professionals
who can meet your needs.
❖ I will maintain written and/or electronic records related to my visits and contact with you to
document your progress and/or activities and resources provided.
❖ I will maintain confidentiality of the details relating to your pregnancy and birth. The exceptions to
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Revised August 2021
 this are if I have first obtained your consent, giving me permission to share details, or if I need to
call in a back-up doula to serve you in some capacity. The back-up doula is also bound to
confidentiality.
❖ For evaluation of the AAIMM Doula Program, I will share data regarding the support I am
providing with DPH evaluation team.
❖ I will wear a face mask covering my mouth and nose and any additional personal protective
equipment during in-person visits during the COVID-19 pandemic.
❖ I will notify you if I have been exposed to a COVID positive person, am experiencing COVID-
related symptoms, or if I test positive for COVID-19.
❖ Throughout your participation in the program, I will provide you (in-person or by mail) gifts for
yourself and baby.
______________
Doula’s initial

Client Obligations

❖ You agree to read and be familiar with the information that I provide to you.
❖ You will discuss your plans for your birth with your provider, preferably before labor.
❖ You will contact me regarding any questions or concerns throughout your pregnancy.
❖ You will take (or have taken) a childbirth preparation class and/or educate yourself about birth.
❖ You will call me (not text) as soon as you think you may be in labor, even if you are not sure, so
that I may make arrangements to be at your birth. You will allow me approximately 1-2 hours to
reach you.
❖ As part of your participation in the AAIMM Doula program, you understand and agree that we may
access your official birth record for evaluation purposes and all data will remain confidential.
❖ You understand and agree that you may be contacted by program and/or evaluation staff for your
feedback in the future.
❖ You will notify your doula if you have been exposed to a COVID positive person, you are
experiencing COVID-related symptoms, or if you test positive for COVID-19.
❖ You agree to wear a face mask covering your mouth and nose during in-person visits during the
COVID-19 pandemic.
___________
Client’s initial

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As an AAIMM Doula, I do NOT:

❖ I do not perform clinical tasks, such as taking blood pressure, fetal heart checks, vaginal exams,
etc. I am there to provide physical comfort, emotional and informational support.
❖ I do not make decisions for you. I will help you get the information necessary to make an informed
decision. I will also remind you if there is a departure from your birth plan.
❖ I do not speak to the staff on your behalf regarding matters in which decisions are made. I will
discuss your concerns with you, suggest options and help you identify key questions that may
help you with your decisions. Discussing your decisions with clinical staff is the responsibility of
you and/or your partner.
❖ I will not prescribe, diagnose or treat any medical problems that may arise and will not be liable
for interpreting diagnostic procedures. This is the role of your care provider.
❖ I do not force my own beliefs regarding the birth process on you. I will support each and every
unique birthing process.
❖ I do not "take over" or deliberately exclude your partner. I am there to provide support to both of
you at all times.
❖ I will not transport you to the hospital or birth center. We will drive separately and meet there.
❖ I do not perform the following services: placenta encapsulation; vaginal steam; herbal
treatments/teas; belly binding; or overnight stays.
___________
Client’s initials

Fees

As a participant in the AAIMM Doula Program, there is no cost to you. You will receive three (3) in
person prenatal visits, continuous labor support, and three (3) in person postpartum visit.
___________
Client’s initials

Failure to Provide Service:

I will make every effort to provide the service described in this agreement. If I am unavailable to attend
your labor, I will provide a back-up doula. This back-up doula, at no cost to you, will be introduced to
you during our prenatal contact (s). ___________
Client’s initials

Cancellation of Contract:
If you choose to cancel this contract, you may do so at any point.
___________
Client’s initials
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Emergency Delivery:

In some circumstances, labor progresses more quickly than anticipated. If you call me to advise that your
labor has progressed very quickly and delivery is imminent or that your baby has been born unexpectedly
at home, I will call an ambulance or ask your partner to do so and arrange for you to be transferred to the
hospital. If your baby arrives unexpectedly at home with me present, you or your partner will be
responsible for the delivery of your baby. I will take what measures I am capable of to attempt to keep you
and the baby safe and comfortable until Emergency Medical Services (EMS) arrives. This will fall under The
Good Samaritan Law.

This agreement is meant to be fair to both parties, so that all parties may feel secure in their mutual
commitment. By signing this contract, client agrees to services as described above and the doula
commits to provide these services. It is understood that neither LA County Department of Public Health
or AAIMM Doula Program or its representatives are to be held responsible or liable for any undesirable
or unexpected outcome resulting from doula support. Should a disagreement occur, the undersigned
agree to resolve issues amicably, therefore excluding DPH and AAIMM Doula Program and its
representatives from any penalty or fault. The signatures below indicate both doula and client
understand the content and terms herein.

I, the undersigned client, hereby warrant that I am competent to contract in my own name. I confirm that I
have read the herein agreement prior to its execution and I am fully familiar with its contents.

Client:
I agree to the terms and conditions of this contract.

First Name: _________ _ _ _ _ _ _ Last Name: ________ _ __ _ _ _ _

Signature: ______________________________________________ Date: ____________________

Doula:
I agree to the terms and conditions of this contract.

First Name: _________ _ _ _ _ _ _ _ Last Name: ________ __ _ _ _ _

Signature: ______________________________________________ Date: ____________________

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 DOULA-CLIENT AGREEMENT FOR SERVICES

AAIMM Doula Program

Client Confidentiality Release Form

This document contains important information about the Health Insurance Portability and Accountability
Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and
disclosure of your Protected Health Information (PHI) for the purposes of client health services and
payment. Confidentiality of medical and personal information obtained during your doula’s work is of the
utmost importance. In general, the law protects the privacy of all communications between you and your
doula, and your doula may not release information about your work together to others without your
written permission. A doula’s failure to comply with this confidentiality form can result in termination from
the AAIMM Doula Program.

I, ___________ _ _ _ _ _ (Client Name), at __________ _ _ _ _ _ _ _ _

________ _____________________________________________________________ (Address),

_________________ (Phone Number), give my permission for my doula __________________ (Name),

to take notes about me, including personal information I choose to disclose to her, and information
regarding my child/ren. I understand that this information will be shared with The Los Angeles County
Department of Public Health AAIMM Doula Program for evaluation purposes only.

____________________________________________________
Client Name

________________________________________________ ______
Signature Date

Revised August 2021

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