BABS

Birth and Baby Services

Offering low-cost & no-cost birth doula services

602-321-0074

Application for our low-cost & no-cost Services

Thank you for your interest in BABS supporting you with your pregnancy and birth. To begin, you will need to review the following forms:

Please understand that even if you meet our qualifications for services, it does not guarantee services will be provided. Our selection committee reviews each application individually and determination for services is made based upon income, the benefit a doula can make to your birth experience, your personal support network and true need of our support.

Check which applies*
Have you been receiving routine prenatal care?*
I want or am open to the following when I am in labor*
Do you agree to be an active part of learning about pregnancy, labor and delivery and participating in our prenatal meetings and read/view educational material and videos.*
I agree that if I get a restraining order against any person including the father of the baby, you will notify us right away. You also understand that BABS may not be able to support you if a restraining is in place.**
Smoking*
Alcohol*
Street drugs or abuse of prescription drugs*
Homeless*
Birthing client, how does your body display tension? Please check all boxes that apply**
Please check all boxes that you have experienced in the past or currently*
Some hospitals have medical students. Are you open to having medical students participate in your labor/delivery?*
BABS has a mentor program for new birth doulas. Are you open to having a BABS mentor student participate in your labor/delivery?**
Check if any of these apply to you:
Note: we will verify all household income and will require copies of the past 2 months income (paycheck stubs or employer verification), a copy of your WIC care if you receive WIC and/or a copy of your AHCCCS card (Mercy care).
Family of 2 - includes you and baby only. (monthly income is take home pay after taxes)
This includes only you and your unborn baby. The father or partner of this baby is NOT in your life and will NOT be involved in this pregnancy, labor and delivery. If at the time of completing your application you do not include the father or partner as a part of your family of 2 and later they do become involved with your pregnancy, labor and delivery making you a family of 3, we will require income documentation from the father or partner and we reserve the right to adjust the determination of no- cost or low-cost and you will be responsible for any fees due.
Family of 3 - includes this baby (monthly income is take home pay after taxes)
This includes you, your unborn baby, the father or partner of the baby if they will be a part of this pregnancy, labor and delivery or another child presently living with you full or part-time. If at the time of completing your application you do not include the father or partner as a part of your family of 3 and later they do become involved with your pregnancy, labor and delivery making you a family of 4, we will require income documentation from the father or partner and we reserve the right to adjust the determination of no- cost or low-cost and you will be responsible for any fees due.
Family of 4 - includes this baby. (monthly income is take home pay after taxes)
This includes you, your unborn baby, the father or partner of the baby if they will be a part of this pregnancy, labor and delivery or other children presently living with you full or part-time. If at the time of completing your application you do not include the father or partner as a part of your family of 4 and later they do become involved with your pregnancy, labor and delivery making you a family of 5, we will require income documentation from the father or partner and we reserve the right to adjust the determination of no- cost or low-cost and you will be responsible for any fees due.
Family of 5- includes this baby. (monthly income is take home pay after taxes)
This includes you, your unborn baby, the father or partner of the baby if they will be a part of this pregnancy, labor and delivery or other children presently living with you full or part-time. If at the time of completing your application you do not include the father or partner as a part of your family of 5 and later they do become involved with your pregnancy, labor and delivery making you a family of 6, we will require income documentation from the father or partner and we reserve the right to adjust the determination of no- cost or low-cost and you will be responsible for any fees due.
Family of 6- includes this baby. (monthly income is take home pay after taxes)
This includes you, your unborn baby, the father or partner of the baby if they will be a part of this pregnancy, labor and delivery or other children presently living with you full or part-time. If at the time of completing your application you do not include the father or partner as a part of your family of 6 and later they do become involved with your pregnancy, labor and delivery making you a family of 7, we will require income documentation from the father or partner and we reserve the right to adjust the determination of no- cost or low-cost and you will be responsible for any fees due.
We are a family of 7 or more including this baby
Our services we be based upon a sliding scale. This includes the father or partner of the baby if they are in your life and other children presently living with you. Please note that if the situation changes and the father or partner does become involved in this pregnancy, we reserve the right to adjust the determination of no-cost or low-cost and you will be responsible for any fees due. If the pregnant person is a minor (17 years or younger) this will then include the parent(s) of the minor if living in the same home and all children living in the same home.
Honesty Agreement*
I/we confirm that all information in this application is true and honest, including income. If your reported income changes during the time that the BABS team is providing support, we reserve the right to adjust your payment for services.
Should you be accepted to receive our servces - *
You MUST participate in ALL scheduled in-person and/or video chat meetings. If you cancel a scheduled meeting more than twice, you do not watch assigned videos or read educational material or actively participate in learning and preparing for your upcoming birth, we reserve the right to end our services with you and if nay fees were paid, they are non-refundable.
Confidentialty/HIPAA Agreement - Check box that applies* The birthing client or parent(s) of the birthing client who is a minor, understand and acknowledge that BABS (Birth and Baby Services) and all doula's associated with BABS (Birth and Baby Services) will have access to the birthing clients medical history, past, present and during labor, after delivery and postpartum. The information obtained may be used for the purpose of doula education and or certification or (re)certification and may be shared with a certification committee and all doulas associated with BABS (Birth and Baby Services). In addition, all information obtained may be used to understand how to best support the birthing client.
Consent or Decline Images taken before, during, after Labor & delivery* BABS - Birth & Baby Services will on occasion take pictures &/or videos on personal cell phones and/or clients cell phones or cameras before, during and after delivery so birthing client &/or spouse/partner can have pictures &/or videos of their birth. All Pictures &/or videos taken are the property of the birthing client &/or spouse/partner and will not be used or shared by BABS – Birth & Baby Services to any person person(s) outside of the client &/or spouse/partner. All pictures or videos taken on doula(s) personal cell phones will be sent to the birthing client &/or spouse/partner's cell phone and then all pictures &/or videos taken will be deleted from the doula(s) personal cell phone.
Consent or decline use of TENS unit* The birthing client does hereby authorize the attending doulas, back up doulas and student doulas to use the TENS unit on birthing client during labor as allowed by the hospital or birth center. The birthing client confirms that they have been shown how the TENS unit works and understands that they can request the use of the TENS unit as long as the medical staff is in agreeance. The TENS unit cannot be used if the birthing client receives an epidural or has any metal in areas the TENS pads would be placed or any open sores. TENS cannot be used by birthing clients with a demand pacemaker, heart disease, epilepsy, in the shower, tube of near water. TENS stands for Transcutaneous Electrical Nerve Stimulation and is applied by means of electro pads which pulses are transmitted across the skin to reduce pain sensation and/or massage based on the TENS unit used. The birthing client will feel a pulsating sensation that may help increase their own pain-relieving chemicals known as endorphins. Birthing client understands that they are using the TENS unit at their own risks and accord and that all BABS – Birth and Baby Service doulas will not be held responsible for any damage the TENS unit can cause the birthing client.
During labor & delivery how would you like the lights in the room?
Would you like battery operated candles used to create a calm birth environment while you are in labor?
We use birth affirmations to encourage & support you, Would you like us to tape them on the walls when in labor?*
Please check all comfort measures you would like during labor/delivery
How do you cope with stress/pain? check all that apply
Please select your level of modesty
Do you agree to be an active part of learning about pregnancy, labor and delivery and participating in our prenatal meetings and read/view educational material and videos?
Please note that if you cancel or do not show up for a scheduled meeting more than 2 times during the time that the BABS team is working with you, BABS reserves the right to suspend our services due to your lace of involvement. If any fees paid will not be refunded. If fees are due. you will receive a bill for them.
Terms of Service*
Due to the demand for our services, you MUST participate in ALL scheduled, in-person and/or video chat meetings. If you cancel a scheduled meeting more than twice, you do not watch assigned videos or read educational material or actively participate in learning and preparing for your upcoming birth, we reserve the right to end our services with you. Any & ALL fees listed above and here within non-refundable and payable at the times stated here within should you change your mind about using our service, not make it to your chosen birth location in time to deliver, or any other circumstances that should arise after signing this work agreement. You will be billed for all applicable service fees not paid should this herein occur.
No guarantee of service*
By checking the following box, you agree and understand that you are completing this application for BABS low-cost and no cost birth doula services and that there in no guarantee that services will be provided. You agree and understand that your completed application will be sent to the BABS review committee to determine eligibility for our services based upon the BABS eligibility criteria. Upon determination of eligibility, you will be sent additional forms to complete and will you will be required to provide BABS with copies of asked for documentation to determines not cost or low-cost eligibility.
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