HeartRoots

Client Confidentiality Release Form

I, __________________________________, at __________________________________ __________________________________ (address), _____________________ (phone #), give my permission for my doula, ___________________________________, 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 child/ren. 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 DONA International. I realize that this information will be shared with the doula that is providing backup support. I also understand that this inform ation will anonymously be used by the DONA Data Collection Committee for statistical purposes, and that my doula may use this information to provide me with a summary for my own personal use.

Signature: __________________________________________

Date: ________________

 

                                                                

                                                              Sharon Jong, www.Heartroots.ca 

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