Consent For Services

Natural Attachment Labor Support

Consent for Services Form

Disclosure of Background & Experience

I, Michele James-Parham, hereby state that I am not a medical physician, registered nurse, doctor of osteopathic medicine, or any other licensed medical practitioner recognized by the laws of the State of Oklahoma. I am, however, an experienced birth doula, natural childbirth educator and traditional lay midwife, but I do not hold any type of medical degree. In the State of Oklahoma, doula services and homebirth are legal. There are no provisions for licensure in the State of Oklahoma for birth doulas, natural childbirth educators or lay midwives. I began my childbirth and doula education in 2000. I have been offering my services openly since early 2004. I am currently involved with obtaining a degree in Naturopathic Medicine (ND) and my Certification in Midwifery. I am also an Ordained Minister, by the Universal Life Church.

My educational background consists of college level instruction in the following areas: Women’s & Family Studies, Crime Victim Survivor Studies, Journalism and Photography, Homeopathy, Herbology, Midwifery, Alcohol and Substance Abuse Counseling, Naturopathy, Religious Education, Educational Reform and Sociology. Other programs and studies completed have been Hypnobirthing Childbirth Classes, Lamaze Childbirth Classes, Bradley Childbirth Classes, Breastfeeding Classes, Nonviolent Interventions, Domestic Violence Support & Intervention, Natural Childbirth Education and Labor Support Roles Education (Doula Studies).

My other educational background consists of numerous seminars, workshops, conferences, and other training and continuing educational pursuits regarding midwifery, maternity care, childbirth education, doula studies and medical and social issues. I have taken seminars about domestic violence and abuse, alcohol and substance abuse, and childbirth safety. I make a point in keeping up to date with the current trends surrounding labor and birth by attending functions and reading medical and childbirth journals and literature.

My professional associations and support include, but may not be limited to, the Midwives Alliance of North America (MANA), the Coalition of Improving Maternity Services (CIMS), the World Health Organization (WHO), BirthPartners, Doulas of North America (DONA), Natural Childbirth Educators United (NCBEU), La Leche League International (LLLI) and Attachment Parenting International (API).

Disclosure of Practice & Philosophy

Natural Attachment labor support services offer safe, gentle, support during labor and birth for pregnant women and their babies regardless of religion, race, alternative lifestyles or ethnic origin. I offer antepartum visits and counseling, birth plan construction, educational support and instruction, home birthing support, labor and birth support and postpartum visits with breastfeeding instruction and support.

Currently, I do not except health insurance, because it is not an option for doulas and childbirth educators. I understand that many families may have insurance that does not cover doula services or childbirth education; with this in mind, I offer economical rates and flexible plans that will work with each individual family’s financial budget. I do ask however that fees be paid up front no later than 37 weeks gestation. I commit myself to providing you with all current information and forms to seek reimbursement from your medical insurance. I do accept credit card payments with Visa, MasterCard, Discover, and American Express, as well as cash, checks, PayPal and money orders.

I believe childbirth is a normal and natural physiologic condition of the female body. I believe women are strong, intelligent, intuitive, spiritual, human beings that are capable of caring for their own bodies and are able to birth their babies naturally, gently, lovingly, and without medications and surgical or medical interventions. I strive to emphasize wellness and preventive measures through education, nutrition, stress relief and management, relaxation, and moderate exercise. I believe that women are able to give birth in the comfort, security, and familiarity of their own homes in the supporting and loving company of their partners, family, friends, and other children. The birthing woman is in charge of her own experience and makes her own choices and decisions about what she wants to experience or not experience during her labor and birth. I am there to assist her in achieving her birthing goals and to help her have a safe and satisfying birth experience. With this said, I also feel it is my duty to support women who need or implore the use of medical interventions and medications and those women who choose or need to birth in a hospital or at a birthing center. I commit to treating all birthing women equally, regardless of their informed decisions.

Acknowledgment of Responsibility

I, the undersigned expectant mother and my partner, if applicable, have been informed by Michele James-Parham, Owner and Director of Services for Natural Attachment, about the services that are provided for my use during my pregnancy, birth, and postpartum time periods through Natural Attachment.

I and my partner, if applicable, will be having a child(ren) and have voluntarily requested Michele James-Parham and her attendants, if any, to assist in the antepartum support , homebirth support or hospital/birthing center support, and postpartum support of myself and my baby(ies). I will not hold Michele James-Parham or any of her attendants responsible for negative outcomes of my birthing experience; these include and are not limited to birth deformities, cesarean birth, infant death or maternal death.

I agree I will not use prescription, over-the-counter drugs or medications, or herbal and nutritional supplements without first discussing my options with my midwife/physician/doula or thorough research on my part. I agree to educate myself about my body, my pregnancy, and about parenting skills. I agree to ask questions about any concerns I may have and to make my own decisions about all aspects of my health care.

I, __________________________, consent to have Michele James-Parham stay with me during my labor and attend the birth of my child(ren) as my (doula/educator/advocate/midwife). I understand the following to be true about Natural Attachment:

• All services are to be paid for; following agreed upon payment schedule.

• Michele will provide antepartum, labor/birth and postpartum support and services, but is not a medical professional.

• Michele might help me through my labor with position changes, massage, breathing techniques, relaxation techniques and/or emotional support.

• Michele will seek assistance from Hospital/Birthing Center staff; if I am not having a homebirth.

• I have the right to ask Michele to leave if I feel her help is no longer needed or to have a transfer to a medical facility.

• Michele will not discuss my condition with my family members or others unless I request her to do so.

• Michele will maintain my patient confidentiality.

• If Michele is unable to stay through my birth, she will do her best to find a competent and caring replacement.

• If I need a Cesarean Section, I want Michele to go with me into the operating room. (Yes/No) Initials ___

• Information about my birth may be used to help gather statistical evidence for the use of (Doulas/Educators/Advocates/Midwives). I realize my name will not be attached to any information used in this process.  (Yes/No) Initials ___

I have read all parts of this letter of consent and initialed where appropriate. I understand all aspects of this letter of consent and all aspects of services provided by Natural Attachment & Michele James-Parham.

_________________________________________            ____________________________________

Client Name                                                                            Partner Name

 

_________________________________________            ____________________________________

Client Signature                                                                      Partner Signature

 

_________________________________________            ____________________________________

Doula/Midwife Signature                                                        Date Signed

 

Download this file here, print and sign, then contact Michele to set up a consultation.

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