Barbara Lehr, Christian Doula

Intake Form

 

Christian Doula

serving laboring women and glorifying Jesus Christ, the Author of Life

Barbara Lehr, ChristianDoula@gmail.com, 219-0622

 

1. Name: ________________

Husband/Partner's Name____________

Birth date: __________________________________

2. Address: _______________________________________________________

3. Home Phone Number: _________________Business Phone Number _________

email address____________________________

4. Number of Previous Pregnancies: ______Miscarriages _______Abortions______

5. Due date______________          Date of last menstrual period______________

Number of Living Children: ______________ When did babies come in relation to your due date?

Premature births (<36 wks.) ___________

6. Have you ever had a C-section? If yes, what were the circumstances surrounding the decision to have a C-section?
________________________________________________________________________

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7. Have you ever had a V-BAC? _________________________________________

8. Who is your careprovider and her/his name? Circle one (OB, Direct-entry Midwife, CNM, CPM, Family Practice MD, Other)


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9. Where do you plan to have your baby? (home, hospital, birth center)?____________­­

10. What is the name of the hospital/birth center? _____________________________

11. Many women today have been sexually abused. During labor and birth these issues can come into play. As your doula I may be of help during labor and delivery if I know this issue exists, and I certainly can begin praying now for this area in your life, and how it might impact you giving birth. If you feel comfortable in sharing this matter with me, I will hold it confidential. However, you do not need to answer this question on this form.

 

12. Do you have any medical problems? If so, please explain. Use the back of this form if there is not enough room.
________________________________________________________________________

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13. Do you have any prenatal complications with this pregnancy: Yes No

Group B Strep ____ ____ Pre-eclampsia ____ ____ Gest. Diabetes ____ ____ IUGR Intrauterine growth restriction) ____ Multiple Pregnancy ____ ____ Preterm Labor ____ ____ AIDS _____ _____ Herpes _____ _____ Other STD's ____ ____ Other (describe) ___________________________________________________

14. What are your feelings about labor and delivery?
________________________________________________________________________

________________________________________________________________________

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15. What is your biggest fear about labor and delivery? ________________________________________________________________________

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16. If you could labor and give birth to your baby anywhere in the world and in any setting, not having to worry about the safety of you and your baby, where would your fantasy birth take place?____________________________________________________

________________________________________________________________________

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17. What kinds of sounds and smells would be surrounding you?


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18. When you are in pain what types of personal comforts do you like to use? (e.g. a quiet room, heat, cold, words spoken, etc).
________________________________________________________________________

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19. Where do you hold tension in your body?
________________________________________________________________________

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20. Do you have medical insurance? Y N

Name of Company

________________________________________________________________________

 

21. Please list any of the following that you have had:

Plant allergies? ____________________________

Latex allergies? ____________________________

drug allergies? _____________________________

History of Drug use? ________________________

 

22. Is there anything in particular you would like for me to be praying about as you approach your due date?

 

________________________________________________________________________

________________________________________________________________________

___________________________________________________________________

 

Labor Phone List

 

Include: Your Doctor or Midwife, Hospital or Birth Center, Hospital Labor & Delivery or Emergency Room, Child and/or Pet Sitters

 

 

Name Title/Description Phone Number(s)

Barbara Lehr, Doula

812-219-0622






























Birth Phone List Include: Family, Friends, Neighbors, Co-Workers, Diaper Service, Baby’s Doctor, Childbirth Educator, Breastfeeding Counselor, etc.

Name Title/Description Phone Number(s)

E-Mail Addresses

If you would like me to email photos of your newborn baby to your friends and family, please send all of the e-mail addresses to me at Christiandoula@gmail.com as soon as possible.

Doula Contract

Christian Doulas

serving laboring women and glorifying Jesus Christ, the Author of Life

Barbara Lehr, christiandoula@gmail.com, 812-219-0622

 

Contract for Doula Services

My Aims:

  • I will pray for you, your husband, and your upcoming birth.
  • I will support you during your pregnancy, labor and in the postpartum period, in whatever choices you make.
  • I will provide information to enable you to make informed choices.
  • I will remain up to date on current research into birth related issues.
  • I will maintain complete confidentiality of all details relating to your pregnancy and birth.
  • I will strive to support you during labor to ensure a positive birth experience and to help you to achieve the type of birth you would like.
  • As I am independent and self-employed, I will be working for you, not your care provider or hospital.
  • I do not perform clinical tasks such as blood pressure or fetal heart rate monitoring. I do provide physical, emotional and educational support. In case of an emergency, unplanned homebirth, I will not deliver your baby. You will be responsible for delivering your baby, but I will continue to provide comfort measures and prayer.

My Duties:

  • I will draw on my knowledge and experience to provide emotional support, physical comfort, and to communicate with the medical staff to make sure you have the information you need to make informed decisions during labor.
  • I can provide reassurance and perspective to you, make suggestions to help labor progress, and help with relaxation, massage, positioning, and other techniques for comfort.
  • I will be on call for you 24 hours a day beginning two (2) weeks before your estimated due date up until labor begins. This means that I will carry my cell phone with me at all times, and will not leave town without advising you unless it is an emergency or an event not known about at the time of this contract signing.

My sliding fee is $500-$700 for my services. Of the $500-$700, a non-refundable deposit of $100.00 is due when you wish to reserve your birth week, with another $200 due by the 38 week; the remaining outstanding amount is due by your due date or the actual birth, whichever comes first. (See below to determine where on the sliding scale your fee will be). In the unlikely circumstance that I am unable to attend your birth, I will send a back up doula, and you will be charged $100 less for the entire birth package. If I miss the birth because you have the baby between the time you call me and the hour it takes for me to be ready to meet you, I will reduce the cost for my services by $100, but will keep the remainder of the fee as payment for prenatal and postpartum care. If the time I am at your labor exceeds 12 hours, I reserve the right to call in back up help in order to leave for 3 hours, so that I might become refreshed and rejuvenated. I also reserve the right to take 3 hour breaks for every 12 hours of laboring. In addition, if the time I am with you exceeds 14 hours, an additional fee of $20/hour will be added to your account. If your birth is outside of Bloomington, I charge an additional $50 to cover travel expenses.

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Particular changes to this contract are as follows:
__________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________

This contract is drawn up and agreed to by the following persons as designated by their signatures below:

____________________________________________ Date:__________

Barbara Lehr, Professional Labor Assistant

(Parents, please print names here):
_______________________________________

_______________________________________

Signatures of Laboring Couple & Date

_______________________________________

_______________________________________

 

Sliding fee: $500 for family income $40,000/year and below; $550 for family income of 40,000-$50,000; $600.00 for incomes $50,000-70,000, $650 for incomes $70,000-100,000, and $700 for incomes over $100,000, please ask to set up a payment plan or to discuss the option of bartering for up to 1/4 of these fees.

Contact Me

Barbara Lehr, Christian Doula

christiandoula@gmail.com

812-219-0622

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