Confidentiality Release Form

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Confidentiality Release Form

The following agreement is hereby entered into between CHRISTIE DONN, MODERN MOTHER GODDESS LLC, referred to as “I,” and the client named and signed on this form, referred to as “you,” with the following conditions understood and accepted by both parties.

I give my permission for my doula, CHRISTIE DONN, MODERN MOTHER GODDESS LLC, to take notes about me, including personal information I choose to disclose to the doula, and information regarding my labor, birth, and postpartum experience, as well as any information regarding my child or children. I understand that this information may be used for the purpose of doula certification or recertification and will be shared with the certification committee of the applicable certifying institution or organization. I realize that this information will be shared with any doula that may be providing backup support. I also understand that this information will anonymously be used by my doula for statistical purposes, and that my doula may use this information to provide me with a summary for my own personal use.

I also understand that Christie Donn, Modern Mother Goddess LLC, operates as a business providing the same or similar services to other clients, and that the sharing with others of their experience with me, my partner, and my baby, will allow others to know about the business and positive client experiences. I also understand that at all times Christie Donn will disclose only the information which I have specifically allowed to be disclosed in this release.

To that end, I allow my doula to share with others, including on social media websites, the following information about my labor, birth, and postpartum experience:

Check the categories of information which you are permitting your doula to share with others.

Date of birth

Time of birth

Location of delivery

Baby’s name

Baby’s first initial

Birthing Parent’s name

Partner’s name

Natural vs. Medicated

Vaginal vs. C-section

Attending midwife’s or Physician’s name

Length of labor

Pictures from birth (that don’t include any exposed body parts,) which will also be shared with you

I/We have read this contract describing the doula’s services and agree to enter into a client-doula relationship for pregnancy and birth.

Please enter your information below and submit this form.

Birthing Person's First and Last Name
*

Birthing Person's Email
*

Estimated Due Date
*

YYYY

Partner's First and Last Name (if applicable)

Partner's Email (if applicable)

By checking this box, you understand and agree that your typed name above will be accepted as your electronic signature on this contract. *

I, the birthing person, understand and agree

I, the partner, understand and agree (if applicable)

Required

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