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Community Doula Program
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Community Doula Program
  • Doulas
    • Want to be a Doula?
    • CDP Doula Private Page
  • Careproviders
  • Families
  • Monarch on 4th
  • About Us
    • Meet the Doulas
  • Media
  • Contact Us
  • Donate

ALL Forms

"*" indicates required fields

1Checklist
2Client Confidentiality Release
3Letter of Agreement
4Data Collection
5Doula Data Survey
6ACEs Questionnaire
7EPDS
8Healthy Families
9Media Release
10Invoice
So we can send you a copy of your form after it's submitted

Required Documents Checklist

Required documents need to be copied and submitted to the CDP. Remember to keep and securely store all original documents.

The information below fills out automatically as you complete the paperwork on the following pages. To advance to the first form, click the "Next" button at the bottom of this page.

Confidentiality Release Form: Incomplete
CDP Letter of Agreement: Incomplete
CDP Data Collection Form: Incomplete
CDP Doula Data Survey: Incomplete
Adverse Childhood Experience (ACE) Questionnaire: Incomplete
Edinburgh Postnatal Depression Scale (EPDS): Incomplete
Healthy Families Consent to Contact: Incomplete
Media Release: Incomplete
Invoice Form: Incomplete

Client Confidentiality Release Form

I,

Client's Name*

give permission for my doula,

Doula's name*
to take notes about me, including any personal information I choose to disclose, and information regarding my labor, birth and postpartum care, as well as any relevant information regarding my family.
I understand that this information may be used for the purpose of providing doula services and for the Oregon Traditional Health Worker registry and will be securely shared and stored by the doula and the CDP. I realize that this information will be shared with any doula that is providing backup support. I also understand that this information will be anonymously used by the CDP for data collection and reporting, and that I can request my doula provide me with a summary for my own personal use. I authorize the release of my information to process claims for billing and for the direct payment of medical benefits to the Community Doula Program.
This field is hidden when viewing the form
If verbal consent, write "N/A"
If verbal consent, type "Verbal Consent"
MM slash DD slash YYYY
Must be signed on or before the date of any billable service

CDP Letter of Agreement

Letter of Agreement for Doula Services

What is a doula?

As a birth doula, I draw on my professional training, knowledge and experience to provide informational, emotional and physical support to help you have the best possible birth experience. I can provide reassurance and perspective to you and your partner, make suggestions for labor progress, and help with relaxation, soothing touch, positioning and other techniques for comfort. As your doula, I am working for you, not your caregiver or the hospital/birth location.

Before labor.

I will meet with you twice before labor to become acquainted, to explore and discuss your priorities and any fears or concerns, to discuss your birth preferences and to plan how we might best work together. During these visits we can include any support people you would like to be a part of the discussion.

I will also inform you of times when I am unavailable for labor support. To cover those times, or in the extremely unlikely event you are unable to reach me when you are in labor, you can call 541-360-8699 to get the support of a qualified backup doula.

Throughout the duration of our time together, we will want to remain in touch by phone, text and/or email.

When you are in labor.

I prefer that you call me when you think you are in labor, even if you do not yet need me. I can answer questions and make suggestions over the phone. We will decide if I should come right then or wait for further change. I usually need approximately one hour to get to you from the time you ask me to come. Except for extraordinary circumstances, I will remain with you throughout labor and birth.

After birth.

I will be there until you are comfortable, and your family is ready for quiet time together, usually 1-2 hours. I can also help with initial breastfeeding, if necessary.

I am available to answer questions about the birth or your baby and would like to get together with you twice within the first six weeks after the birth to see how you and your baby are doing and provide support and referrals.

What doulas do NOT do.

As a doula, I do not:

- Perform clinical tasks, such as blood pressure, fetal heart checks, or vaginal exams.

- 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 preferences.

- Speak to the staff on your behalf. I will discuss your concerns with you and suggest options, but you or your partner will speak directly to the clinical staff.

- Provide transportation.

- Provide interpretive services.

- Provide childcare.

Failure of a doula to provide service.

I will make every effort to provide the services described here. Sometimes this is impossible (for example, with rapid labor). If my failure to attend your birth is due to my error or you have complaints about my services, you can notify the Community Doula Program coordinator Roslyn Burmood at roslyn@communitydoulaprogram.org, 541-760-3656.

Fees.

The Community Doula Program’s services are reimbursed 100% by the state of Oregon for all IHN-CCO clients. You give your consent for the program to bill and be reimbursed for services we provide for you.

If your insurance changes, please inform the program coordinator as soon as possible.

I/We have read this letter describing the doula's services and agree that it reflects the discussion we had with them.

This field is hidden when viewing the form
If verbal consent, write "N/A"
If verbal consent, type "verbal consent".
MM slash DD slash YYYY

CDP Data Collection Form

Administration

Doula Information

Doula Name
Close the Loop
Checking this box will send an email to the referral coordinator, referrer and client.

Referrer Information

Referrer Name

Client Personal Information

Client Name
MM slash DD slash YYYY
Client Partner/Husband Name
MM slash DD slash YYYY
MM slash DD slash YYYY
First Pregnancy?
Client Address

Insurance Information

(i.e. IHN, Providence, CAWEM)
Is primary or secondary insurance is under a person other than the client?
If primary or secondary insurance is under a person other than the client, record the other person’s full name, DOB, address, & telephone number. The CDP can NOT bill insurance if this is missing. If in doubt, confirm insurance coverage with the Program Manager prior to providing services.
Primary Insured's Name
MM slash DD slash YYYY
(i.e. IHN, Providence, CAWEM)
Secondary Insured's Name
MM slash DD slash YYYY
Secondary Insured Address
(If different than Client's address)

Doula Service Information

MM slash DD slash YYYY
Location

Prenatal Services

MM slash DD slash YYYY
Location of 1st Prenatal
Include topics covered and referrals
MM slash DD slash YYYY
Location of 2nd Prenatal
Include topics covered and referrals
Birth Plan Prepared

Labor & Delivery Services

MM slash DD slash YYYY
Time of Doula Arrival
:
Client birthed?
MM slash DD slash YYYY
Time of Doula Departure
:
MM slash DD slash YYYY
Where was baby born?
Mode of Birth
Include details of the labor and delivery

Postpartum Services

MM slash DD slash YYYY
Location of 1st Postpartum
Include topics covered and referrals
MM slash DD slash YYYY
Location of 2nd Postpartum
Include topics covered and referrals

Additional Visits

There is limited funding available to provide additional billable / reimbursable postpartum visits. Contact Heidi Donahue at referrals@communitydoulaprogram.org to request approval to provide additional paid postpartum visits.

MM slash DD slash YYYY
Location of 3rd Postpartum
MM slash DD slash YYYY
Location of 4th Postpartum

CDP Doula Data Survey

It's required that you enter the data on this form into the online database, Tinyurl.com/DoulaCDP.

Client Name
Client Insurance

Check All Services Provided

Global Package: 2 Prenatal, Birth, 2 Postpartum
Individual Services (IF NOT a Global package)
Provider type
Did you drive client in YOUR car to:
Did you drive client in THEIR car to:
Was this an Insta-doula Birth?
Did you work with a backup doula for this birth?
Was this person also a client of Nurture Oregon?
What level of education does the client have?

Which priority population(s) does the client belong to? Please choose one answer for each.

Racial/ethnic minority
Limited/no English
Homeless/underhoused
Client is <21
Limited/no social support
Medically high risk
Racial or ethnic minority group this client identifies with (check all that apply)
Is client non-cis gender (LGBTQ(UAI2S)+, etc.)?
What languages does the client speak?
Did you provide interpretive services for the client?
MM slash DD slash YYYY
Primipara (First Birth)
Had client ever had a prior cesarean?
Had client ever had a prior vaginal birth?
Was this pregnancy multiples (twins, etc.)?
Was the baby breech?
Prior to birth was client planning to breast/chestfeed?
Went to Emergency room during pregnancy?
Did you attend the birth for this client?
If no, why did you not attend this client's labor?
Did you provide support after labor began but before the client went to the birth center/hospital?
MM slash DD slash YYYY
Just before labor, client was planning birth at:
Where was the baby born?
Planned Mode of Birth
Actual Mode of Birth
What kind of maternity care provider was the client seeing for most of their pregnancy?
What kind of provider was attending the birth when the baby was born?
For instance, if a midwife was managing the client's labor, but an obstetrician was called at the end for a complication, please list "obstetrician."
Methods of pain relief during labor
Epidural
Nitrous Oxide (gas)
IV opioids
Pool or tub
Shower
Massage
Movement
Who was the primary attendant at this client's labor and birth?
By "primary attendant" we mean the person who was providing care most of the time during labor, even if someone else was there (maybe at the end).
Did the client require stitches to repair their genital tract?
Who caught the baby?
Was the baby born:
The above is listed in:
Was the baby admitted to the NICU?
Did the client and baby go home from the hospital at the same time?
After discharge, was the baby readmitted to the hospital?
After discharge, was the client readmitted to the hospital?
After birth, did the client go to the Emergency Room?
After birth, did the baby go to the Emergency Room?
The last time you saw the client was the baby being breast/chestfed?
Did the client relinquish their baby after birth?
Healthy Families Referral
Did you discuss post pregnancy birth control options with this client?
Did this client attend their 6 week visit with their obstetrician/midwife?
Might need to double check questions/responses when client is having twins (some of the answers don’t align with the question being asked).

Adverse Childhood Experience (ACE) Questionnaire

Name

While you were growing up, during your first 18 years of life:

Did a parent or other adult in the household often swear at you, insult you, put you down, or humiliate you? OR Act in a way that made you afraid that you might be physically hurt?
Did a parent or other adult in the household often push, grab, slap, or throw something at you? OR Ever hit you so hard that you had marks or were injured?
Did an adult or person at least 5 years older than you ever touch or fondle you or have you touch their body in a sexual way? OR Try to or actually have oral, anal, or vaginal sex with you?
Did you often feel that no one in your family loved you or thought you were important or special? OR Your family didn’t look out for each other, feel close to each other, or support each other?
Did you often feel that you didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? OR Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
Were your parents ever separated OR divorced?
Was your mother or stepmother: Often pushed, grabbed, slapped, or had something thrown at her? OR Sometimes or often kicked, bitten, hit with a fist, or hit with something hard? OR Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
Was a household member depressed or mentally ill or did a household member attempt suicide?
Did a household member go to prison?
/10

Edinburgh Postnatal Depression Scale (EPDS)

As you are pregnant or have recently had a baby, we would like to know how you are feeling. Please check the answer that comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feel today.

Here is an example, already completed.

I have felt happy:
â–¡ Yes, all the time
☒ Yes, most of the time
â–¡ No, not very often
â–¡ No, not at all

This would mean: "I have felt happy most of the time" during the past week. Please complete the other questions in the same way.

In the past 7 days:

I have been able to laugh and see the funny side of things
I have looked forward with enjoyment to things
I have blamed myself unnecessarily when things went wrong
I have been anxious or worried for no good reason
I have felt scared or panicky for no very good reason
Things have been getting on top of me
I have been so unhappy that I have had difficulty sleeping
I have felt sad or miserable
I have been so unhappy that I have been crying
The thought of harming myself has occurred to me
/30

Maximum Score: 30
Possible Depression: 10 or greater
*Always look at item 10 (suicidal thoughts)

Healthy Families Consent to Contact

Give Your Baby a Healthy Start!
Because babies don’t come with an instruction book!


Having a child brings big changes in your life. Healthy Families of Linn and Benton Counties is available to
parents who are pregnant with or have given birth within the last three months. This program is
voluntary, and it is free! There are no income requirements.

 

Healthy Families of Linn and Benton Counties offers:
 

➢ The latest information about how babies grow, develop and learn both physically and emotionally
➢ Ways to bond with your baby
➢ Information about how to keep your family healthy
➢ Tips for parents about infant sleep, play, and attachment, and many more
➢ Information about other community resources, like breastfeeding support and car seat installation
➢ Home visits for parents and their children

 

If you are interested in hearing more about the Healthy Families program in your community, please
complete the information below. Someone from Healthy Families will contact you soon!

 

I am interested in getting more information about Healthy Families (site name).
Important: To have this referral sent, you must check "Yes", complete the fields below, AND click Save & Continue at the bottom of the page.
Your Name
MM slash DD slash YYYY
Address
Baby's Name
MM slash DD slash YYYY
Baby's Gender
MM slash DD slash YYYY
Are you a tribal member?

Important: To have this referral sent, you must check "Yes" to I am interested in getting more information about Healthy Families (site name), complete the fields above, AND click Save & Continue at the bottom of the page.

If you have any questions or concerns, please send an email to admin@communitydoulaprogram.org.
 

Media Release

I hereby authorize the Community Doula Program, including authorized representatives and successors to use, reproduce, and/or publish photographs and/or video that may pertain to me and/or my minor child(ren) including images or likeness, without compensation.

I understand that this material may be used in various publications, public affairs releases, recruitment materials, broadcast public service advertising (PSAs), outreach or for other related endeavors.

This material may also appear on the Organization's or project sponsor's Internet Web Page or social media sites, including but not limited to the Community Doula Program website, Facebook, Instagram, Twitter, Pinterest or YouTube.

I approve the use of the finished photograph by the Organization only for non-commercial, non-profit purposes. I disapprove of any other use of the photograph, including (but not limited to) any commercial use or resale or relicensing of the photograph (or any variation thereof) by the Organization and/or to any other party.

I have permission from the photographer to share the use of this photo with the Organization.

This authorization is continuous and may only be withdrawn by my specific rescission of this authorization, which may be retroactive.

Declaration: I have read this Consent and Waiver and understand its contents are legally binding.

Name:
This field is hidden when viewing the form
Required if client opted to complete this form
MM slash DD slash YYYY
Required if client opted to complete this form
Drop files here or
Max. file size: 64 MB.

    Invoice Form

    MM slash DD slash YYYY
    Did your address change?
    New Address
    Did you provide global care or fee for service?
    Note: Global care includes: 2 prenatal, birth, 2 pospartum
    If you provided Fee for Service, please check all that apply.
    This field is hidden when viewing the form
    Additional Postpartum Visits
    Note: To be reimbursed, additional postpartum visits require pre-approval from Heidi Donahue.

    Thank you to our funders:

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    The Community Doula Program and Monarch on 4th are both programs of Heart of the Valley Birth and Beyond, a 501(c) non-profit. HVBB's EIN: 45-3735093

    © 2024 Community Doula Program. All Rights Reserved.

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