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Community Doula Program
  • Find a Doula
  • Refiera a un cliente
  • Doulas
    • Become a Doula
  • Classes & Resources
  • Acerca de Nosotros
    • Staff Members
    • Board Members
    • Conoce a las Doulas
    • Medios de Comunicación
  • Comuniquese con Nosotros
  • Donaciones
  • Blog

ALL Forms

"*" indica campos obligatorios

1Lista de Verificación
2Liberación de confidencialidad del cliente
3Carta de acuerdo
4Data Collection
5Doula Data Survey
6Invoice
7Referral Check Sheet
Para que podamos enviarle una copia de su formulario después de enviarlo.

Lista de verificación de documentos requeridos

Los documentos requeridos deben copiarse y enviarse al CDP. Recuerde conservar y almacenar de forma segura todos documentos originales.

La siguiente información se completa automáticamente a medida que usted completa la documentación en las siguientes páginas. Para avanzar al primer formulario, haga clic en el botón "Siguiente" en la parte inferior de esta página.

Formulario de liberación de confidencialidad: incompleto
Carta de acuerdo de CDP: incompleto
Formulario de recopilación de datos de CDP: incompleto
Encuesta de datos de CDP Doula: incompleto
CDP Client Characteristics: incompleto
Formulario de factura: incompleto
Referral Check Sheet: incompleto

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.
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Clear Signature
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

Carta de acuerdo de CDP

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 can provide a total of 8 visits split between before and after birth. I will meet with you 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. I will make every effort to provide the services described here. Sometimes this is impossible (for example, with a rapid labor). To cover those times, or in the extremely unlikely event you are unable to reach me when you are in labor, you can contact my backup doula - I will provide contact information.

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. We will also decide where to meet; your home, the hospital, or the birth center. 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 or up to four times after the birth to see how you and your baby are doing, to review the birth, 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.

Emergency Backup Support:

In the unlikely event you are unable to reach me or your back-up doula, call (541) 224-5004 to reach our on-call doula. They are available 24/7.

Failure of a doula to provide service.

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 at admin@communitydoulaprogram.org or (541) 224-5004, option #3

Fees.

The Community Doula Program’s services are reimbursed 100% by the state of Oregon for all Medicaid 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 me as soon as possible as this could affect reimbursement and my ability to serve you.

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

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Clear Signature
If verbal consent, write "N/A"
If verbal consent, type "verbal consent".
MM slash DD slash YYYY

Formulario de recopilación de datos de CDP

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 at referrals@communitydoulaprogram.org 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
Other Insured Address
(If different than Client's address)
Medicaid Priority Population(s) (check all that apply)

Doula Meet & Greet

MM slash DD slash YYYY
Location

Billable 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)
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CDP Client Characteristics

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Did you attend the birth for this client?
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Was this an InstaDoula birth?
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Did you provide any (unpaid) interpretive services foir this client?
Which priority population(s) does the client belong to?Please choose one answer for each. This is important for reporting back to IHN! Please take time to answer as completely as possible.
Racial/Ethnic Minority
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Limited/No English
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Homeless/Underhoused
Client is <21
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Limited/No Social Support
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Medically High Risk
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Racial or ethnic group(s) this client identifies with (check all that apply):
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Mode of Birth
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Before this birth, had the client ever had a cesarean?
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Before this birth, had the client ever had a vaginal birth? Please include past live births and past stillbirths, excluding miscarriages.
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Was this pregnancy multiples (twins, triplets, etc.)?
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Was the baby born...
Baby's birth weight:
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Before the birth, was this client planning to breastfeed/chestfeed this child?
For instance, baby was stillborn, or postpartum depression/psychosis? Anything particularly good like the L&D was very welcoming?
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The last time you saw this client, was this baby being breast/chestfed?

Encuesta de datos de CDP Doula

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
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Did you drive client in YOUR car to:
Did you drive client in THEIR car to:
Was this an Insta-doula Birth?
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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).

Formulario de factura

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.
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Additional Postpartum Visits
Note: To be reimbursed, additional postpartum visits require pre-approval from Heidi Donahue.

Referral Check Sheet

Please check off any referrals that you have made. Check all that apply.
Referrals were made to the following:
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Thank you to our funders:

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The Community Doula Program is a program of Heart of the Valley Birth and Beyond, a 501(c)3 non-profit. HVBB's EIN: 45-3735093

Thank you to our funders:

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The Community Doula Program is a program of Heart of the Valley Birth and Beyond, a 501(c)3 non-profit. HVBB's EIN: 45-3735093

© 2025 Community Doula Program. All Rights Reserved.

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