General Information About You:

Healthcare Provider & Birth Location:

Reason You Need Postpartum Doula Assistance:

If you select "Yes": Complete the rest of the Form including all remaining fields.
If you select "No", Complete MC Client Confidentiality & Consent Statement Below & Press "Submit Registration Form"

More About You & Pregnancy History:

For Pricing, visit our Postpartum Doula Page HERE or contact us:  momsdoula@mcdsonlinedoulas.com

*IMPORTANT* - It can be difficult for some of us to share about an experience that we may still be recovering from emotionally, physically or mentally; especially if it was difficult or traumatic. It is not our intention to retrigger or reopen any emotional wounds or memories surrounding that event. Sharing a bit about the current or previous birth and or postpartum experience can help us introduce you to a Doula who may have worked with clients who have experienced birth or postpartum trauma.  RECENTLY GAVE BIRTH OR PREVIOUS BIRTH EXPERIENCE: Can you share a brief summary about what you expected your labor and birth would be like and if what actually happened was different?  How did your Birth experience affect your physical, emotional and mental health?  PREVIOUS OR CURRENT POSTPARTUM EXPERIENCE: Can you share a brief summary about what you expected your postpartum experience to be and if what actually happened was different?  How did your Postpartum experience affect your physical, emotional and mental health? 

Postpartum & Infant Preferences, Goals & Doula Specifics:

Confidentiality of medical and personal information obtained during the course of the Doula’s work is of the utmost importance. Due to current confidentiality regulations we must have a signed your permission to collect any information about you that includes: your contact info, details about your current or previous pregnancies, most recent or previous birth experience(s), the plans you have or had for labor, birth and postpartum, info about your spouse/partner and family (children) and any other information you've included in this Registration Form.  We will keep a copy of this Confidentiality & Consent Form to demonstrate that Mother’s Care and your Doula are indeed complying with the confidentiality regulations if questioned. Failure to comply with these confidentiality regulations could result in penalties. 

I authorize Mother’s Care Doula Services, Inc. (MC), which includes the Doula I will ultimately work with and the MC Backup Doula Support Team, to take notes about me, including personal information I included in this Registration Form and any other information about me that I choose to disclose including but not limited to: my contact info and the contact info of anyone I included in this form (phone numbers, emails, addresses),  information regarding my health history and or current health, details regarding previous pregnancies and birth experiences and this current pregnancy, my plans, goals and preferences for labor, birth and postpartum, information I share about my spouse or partner and or other close or extended family members, children and or friends and acquaintances and information related to my baby's health. 

I authorize MCs Service Coordinators to collect the information in the Registration Form and use it to help me select the best Doula for me and later to be used by my Primary Doula and MCs Backup Doula Staff. This information might also be used to provide me with a summary of my experience for my own personal use if I request it. 

I understand that the information contained in this Registration Form will not be shared with anyone outside of MCs Leadership & Doula Staff unless I give authorization and consent (see below). 

IF REQUIRED FOR DOULA CERTIFICATION OR RECERTIFICATION: I authorize MC to share the following information with DONA International for the purpose of Doula Certification (if I work with a Doula in Training) or Recertification (if I work with a Certified / Experienced Doula):  the date of my baby's birth, state my baby was born in, what comfort measures and strategies for labor and birth were used, and medical interventions and or medications that were used, the outcome of the birth (vaginal or cesarean), what my postpartum goals and plans were in relation to infant feeding preferences and the routine care practices normally used by postpartum doulas along with the fact that I hired and worked with a Postpartum Doula.  

• WILL MY PERSONAL IDENTIFYING INFORMATION BE SHARED WITH DONA INTERNATIONAL OR ANYONE OUTSIDE OF MC?  I understand that NONE of my personal contact information or my identity including my name, phone numbers, address, emails, name of my spouse/partner, children or other personal identifying information will NOT be shared with anyone outside of MC and will be kept anonymous.

I understand that if I have any questions / concerns about how the information contained in this form is used I can email MC at momsdoula@mcdsonlinedoulas.com or contact MC at: 954-433-CARE (2273).

SUBMIT MY REGISTRATION FORM!