Confidentiality Agreement
CONFIDENTIALITY
I, _________________, give permission for my doula, ___________________ to make and keep notes about me, including any personal information I may disclose, information regarding my health, pregnancy, care plan, birth and postpartum plans, as well as any information about my family. I consent to my doula sharing my basic information:
​
-
with their back up doula in order to provide continuous care in the event that transition of care becomes necessary (emergent situations, long labors, etc.)
-
for statistical or educational purposes, and that my doula may use non-identifying information for research, learning, and improvement
-
to create informational or marketing resources for my doula's business
-
to provide me, the client, with a summary of my support services
​
​I understand that in all other ways, my information will remain confidential. My information will be securely held by my doula for one year after the completion of my support services.