Letter of Agreement for Virtual Birth/Postpartum Peer Support Services and Fee Contract
As a certified peer counselor I am dedicated to supporting and empowering families. I go about this with transparency and communication. These are the terms and agreements for my services.
My role: I am a Certified Peer Counselor that provides strengths based peer support, childbirth education, and targeted resource and referral support. I provide emotional support and wellness planning while providing evidence based peer support.
Services: I provide virtual support, (unless contracted for In-Person support, separate service/agreement) via email, text, phone, and virtual video platforms.
You agree to participate in the planning of your birth and to communicate openly with peer counselor about any questions, concerns, about your pregnancy or birth, special needs, health issues, medical concerns, emotional situations or concerns.
You understand birth is a natural process and in order to have the birth you desire you must be willing to participate fully in planning, communication with everyone involved.
Peer Counselor will maintain confidentiality of all personal and medical information shared by the client. Peer counselor will not disclose when someone is in labor, if they have given birth, details about their birth, or information about their baby. It is also confidential when a person is a client.
As a Peer Counselor I do not perform clinical tasks. I refer out when necessary to the proper medical professionals. I do not make decisions for you. I will help you get the information that you need to make informed decisions. I do not speak to medical staff or providers on your behalf. I will discuss your concerns with you, work on self advocacy skills and suggest options, as well as encourage you and your partner/spouse to voice your opinions, questions and concerns to the staff. I do not provide medical advice. I can direct you to resources that might help you answer your questions and make informed decisions on your own. If you have questions or want advice about your care or that of your baby, you should contact your care provider.
In entering a contract for peer support services with Luz De La Luna Services, I acknowledge that during the performance period of this contract, services will be provided to me virtually. I understand that Luz De La Luna has a limited role pursuant to the description of tasks outlined in the above-referenced contract wherever services are provided to me.
Luz De La Luna has not presented to me that contracting for services guarantees in any way a risk-free or emergency-free labor and birth experience. I understand that my Peer Counselor does not make medical decisions on my behalf, to include the decision when to seek medical care at a hospital when labor support services are provided in my home. I acknowledge that Luz De La Luna is not responsible for the performance of clinical tasks to include medical decisions regarding the inclusion or exclusion of treatments available to me and my baby.
Non-refundable deposit is due upon signing terms. Remainder due 4 weeks before service end date. The retainer/deposit fee secures the client’s due date and peer counselors availability for that month.
If the client wishes to end services before the birth, all but the retainer fee will be refunded. If peer counselor is unable to support the birth through no fault of their own (i.e. the client did not notify in a timely manner), no refund is given.
If peer counselor is unable to support client due to their own circumstances (such as illness), 50% of the total package fee is returned.
I have read and understand the terms for Virtual Birth/Postpartum peer services. I agree to take full responsibility for all my health care decisions. Luz De La Luna Services will not be held liable for any consequence to me, resulting from decisions that I make regarding my pregnancy, labor, or birth. I recognize that Luz De La Luna Services are not medical professionals and not responsible for any health outcomes resulting from the services retained.
I have read all statements and I fully realize that I am signing a complete release to any claims which I have or believe I have resulted from our contract for peer services.
Booking Policy for Wix
Pregnancy/PP
For Packages: Non-refundable deposit is due upon signing terms. Remainder due 4 weeks before service end date. The retainer/deposit fee secures the client’s due date and peer counselors availability for that month.
If the client wishes to end services before the birth, all but the retainer fee will be refunded. If peer counselor is unable to support the birth through no fault of their own (i.e. the client did not notify in a timely manner), no refund is given.
If peer counselor is unable to support client due to their own circumstances (such as illness), 50% of the total package fee is returned.
Cancellation/Rescheduling
Peer counselor will give 24hrs notice (when possible) of any scheduling changes.
Clients will notify peer counselor of scheduling changes/cancellations within 24 hours.
I acknowledge services will be provided to me virtually. I recognize that Luz De La Luna Services are not medical professionals and not responsible for any health outcomes resulting from the services retained.
General Peer
For Packages: Non-refundable deposit is due upon scheduling the first session. Remainder due 4 weeks before service end date. The retainer/deposit fee secures the peer counselors availability for that time.
If the client wishes to end services, all but the retainer fee will be refunded. If peer counselor is unable to support through no fault of their own (i.e. the client did not schedule sessions), no refund is given.
If peer counselor is unable to support client due to their own circumstances (such as illness), 50% of the total package fee is returned.
Cancellation/Rescheduling
Peer counselor will give 24hrs notice (when possible) of any scheduling changes.
Clients will notify peer counselor of scheduling changes/cancellations within 24 hours.
I acknowledge services will be provided to me virtually. I recognize that Luz De La Luna Services are not medical professionals and not responsible for any health outcomes resulting from the services retained.