Mum's Name *
Mum's Name
Partner's Name *
Partner's Name
Care Provider Information
Labour & Birth Feelings
Your primary caregiver is your doctor or midwife
I would strongly suggest asking your birth partner to answer this in their own words.
Health Information
In the last 6 months have you been tested for: *
Please select all that apply
Were all tests negative? *
Pregnancy Information
Pregnancy-related complications or special circumstances *
e.g. IVF, IUI, PGD, donor
Please give detail on the following for each previous pregnancy/birth: YEAR, GESTATION, LENGTH OF LABOUR, INTERVENTIONS, OUTCOME
Please let me know about anything that may help me help you.
The ‘baby blues’ are a known symptom of birth and mothers are told to expect to feel sad, anxious and very emotional around the third day after the birth, usually when the milk engorges the breasts. These symptoms can sometimes develop into postnatal depression and mothers with a history of anxiety and depression are considered higher risk of developing PND. Studies have proven that the symptoms of postnatal depression are linked with the severe lack of essential nutrients such as vitamin B6 and hormone CRH (our stress reducer hormone), both which are of high supply in the placenta. Consuming the placenta in raw smoothies or in capsules is believed to replace lost essential nutrients and hormones and may contribute towards prevention of the ‘baby blues’ and postnatal depression.*Medications - When prescribed for a pregnant mum, the medication is usually considered safe and usually regular medication is not retained by the placenta in significant enough quantities to be a problem when ingested. However we do advise you to seek the advice of your doctor.
Birth Preparation
What are your expectations of your doula? How do you think I can best support you and your family? Every family is different and has different needs so please use this space to be as specific as you can be.
It is interesting that these same comfort measures are likely to be the same things that comfort you during labour.
It is interesting that these same strategies are likely to be the same strategies that come naturally to you during labour.
It is interesting that these same strategies are likely to be the same strategies that come naturally to you during labour.
Have you written your Birth Plan/Preferences? *
To be able to support you, a birth plan is crucial to be able to show your care providers should questions arise about your preferences. Here is a link to my favourite birth plan kit which demystifies your options: https://nancymcleanblog.files.wordpress.com/2016/10/birth-plan-kit-rethink-birth.pdf
If you would like to explore this further, you can start with the worksheet here: http://www.transitiontoparenthood.com/ttp/foreducators/handouts/Coping2.pdf
Do you want photography/video of labour and birth? *
Please specify any restrictions and/or requests.
TRAVEL FEES
I live in Cronulla and travel throughout Sydney to clients who live roughly within a 1 hour drive. Travel is charged at $20/hr.
Payment Method *
Cash is always preferred! .x
Services *
Please select all that apply
Are you interested in placenta remedies? *
e.g. encapsulation
If you have any questions or specifications please note them here. Thanks!
Terms and Conditions *
1. A Doula does not have any clinical responsibility and will not: - Perform any medical procedure, including taking blood pressure, foetal assessments, vaginal examinations or taking temperature - Give medical advice, recommend medical treatment, or diagnose - Replace a trained lactation consultant. 2. Clients who choose to utilise items the Doula provides - including but not limited to - heat packs and essential oils, take full responsibility for their own health and for researching and using the equipment or remedies available. The Client agrees that the Doula is not liable and does not take responsibility for any results or effects the Client may experience as a result. 3. The Client will be liable for damaged property and/or equipment belonging to the Doula should any equipment become broken and/or damaged whilst in the Client’s care. 4. The Client consents to the attendance of the Doula to the extent necessary to support her through labour and delivery. In the event the Client does not call the Doula, or give the Doula reasonable notice, or the Doula is not permitted by the attending doctor/hospital no refund will be given. 5. The Doula reserves the right to withdraw service at any time due to conflict or personal health or safety concerns - including but not limited to any kind of abuse, passive or second-hand smoke and aggressive pets. If deemed reasonable, the Doula will seek the services of a replacement doula to support the Client. If services are withdrawn by the Doula, all fees less those for services already rendered will be refunded. The breakdown of fees for the purposes of a refund are; antenatal session = 15%, 1 week on call = 10%, birth support = 30%. 6. The Doula reserves the right to refuse transport of the Client - including any family member - in her personal car due to liability concerns in case of an accident. 7. Should an unexpected caesarean occur before the due date, the Doula will support the Client through that birth experience and help the Client prepare for the best outcome for her, her partner and her baby. 6. The Client agrees to complete a Feedback Form online, answering questions honestly to help provide statistics and testimonials for the Doula. 8. A 50% deposit is required to secure your booking and is non-refundable. Full upfront payment is appreciated however payment plans are available, provided full payment is complete before 37 weeks gestation. Should a cancellation occur before the on-call period commences, you will be refunded everything paid over the deposit amount. 9. Full payment of yoga, massage and postnatal sessions is required before or on the day of service. If prepayment is made by bank transfer, funds must be visible in the receiving account before the service is carried out. 10. Cancellations of yoga, massage and postnatal sessions must be made with a minimum of 48 hours notice otherwise a 50% fee will be charged. 11. A 50% surcharge may be applied for scheduled services required outside of Monday-Friday 10am-6pm if reasonable attempts between the Client and the Doula are not made to find a mutually agreeable time. Public holidays are charged at 100% surcharge. This does not apply to attending your birth. 12. The Doula will be available via phone (voice and video) throughout the Client's early labour and will join the Client to support active labour and delivery. 13. It is the Client's responsibility to stay in close contact and notify the Doula of any sign of labour and when planning to have the Doula join, allow a minimum of 1 hour plus travel time for the Doula to arrange care for her own child and arrive. 14. Please be considerate of the Doula's own health needs. The Doula's role is to prioritise the Client's needs and will not take any incidences of leaving the Client lightly, however as an breastfeeding mother, occasional pumping or feeding of her child may be required. Important Disclaimer Please note: Doula's do not give medical advice and always recommend you seek advice from a registered health professional. By checking the box below you agree that all the information you have given is correct to the best of your knowledge. You also agree to the Terms and Conditions above.

If you chose to pay by cash/bank transfer, you will shortly receive an invoice. Your booking will be considered confirmed once your 50% deposit has been received.

Please contact me if you have any questions or queries by emailing nancy@nancymclean.com.au or call/text 0427 963 388.

- Rest, relax and trust in your natural ability to birth beautifully!