Client Code:CDP799

CDP Data Collection Form

EDD: 12/09/2021

First Pregnancy?
  • No

Where did the client give birth? n/a

Provider: n/a

Primary Insurance: IHN

Priority Medicaid Populations (check all that apply):
  • Medically high risk

Date of Referral: 11/23/2021

Doula: Heidi Donahue

Meet and Greet Date: 12/06/2021

Method: phone

Date of 1st Prenatal: 12/06/2021

1st Prenatal Attended By: Heidi Donahue

Location of 1st Prenatal: Zoom

Time: 1 hour

Notes:

introductions, has client tell me about current pregnancy and what her hopes for delivery are. she had a cesarean with her last birth, after repeated decels from baby and she really would like to have a VBAC with this baby. We talked about her current support system, and how a doula could help her feel more informed and supported during this labor. explained what a doula does/does not do. she was referred by her provider and wasn't sure if her husband would be on board with having me there with them during the birth so she said she would message me the next day after a chance to talk with him. She called me the next day and said that yes, they both would like doula support at the delivery.

Date of 2nd Prenatal: 12/11/2021

2nd Prenatal Attended By: Heidi Donahue

Location of 2nd Prenatal: Zoom

Time: 1 hour

Notes:

spoke more in depth about the physical things I could do to help during labor for pain relief and what she would be comfortable with, and how involved her husband wanted to be in a hands on way during labor, developed a birth plan, and talked about when to call me and when I would show up.

Total Prenatal Hours With Client: 2.5 hours

# of telehealth/in person visits during course of care: 2

# of text messages during course of care: 30

# of phone calls during course of care: 2

Date Created: December 30, 2021


Invoice Form (Credentialed Doulas)

Invoice Date: 12/30/2021

Check All Services Provided:
  • Prenatal Visit 1
  • Prenatal Visit 2


Client Confidentiality Release Form

Doula's name: Heidi Donahue

Date signed: 12/06/2021

Date of birth: 08/24/1991


CDP Letter of Agreement

Client signature:

Date signed: 12/06/2021


Required Documents Checklist

Confidentiality Release Form:
  • Completed

CDP Data Collection Form:
  • Completed

Invoice:
  • Completed

Entry date: March 31, 2022