Client Confidentiality Release Form
Due to current client confidentiality regulations, all doulas should have a signed release form from their clients before taken any notes about her or her labor, birth, or postpartum. The client will receive a copy of the form she has signed, and the doula shall have her copy with her at all times to be able to show that she is indeed complying with the confidentiality regulations if questioned. Confidentiality of medical and personal information obtained during the course of the doula’s work is of utmost importance.
I,:
at:(address),
(phone #)
give permission for my doula, Lisa Patterson, to take notes about me, including personal information I choose to disclose to her, and information regarding my labor, birth, and postpartum, as well as any information regarding my children. I understand that this information may be used for the purpose of doula certification and will be shared with the Certification Committee of Childbirth and Postpartum Professional Association (CAPPA). I also understand that this
information may anonymously be used for data collection for statistical purposes, and that Lisa may use this information to provide me with a summary for my own personal use. I also understand that Lisa will glean lessons that she learned as a doula during her experience serving you and may post them on her blog. No names or highly detailed descriptions of the labor and birth will be mentioned in her blog entry. I understand and acknowledge this and hereby consent to such use of my personal and medical information.
Signature:
Date:
