Client Confidentiality Release Form

I give permission for my doula, Josephine D. Wright, to take notes about me, including personal information I choose to disclose, 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 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 information will anonymously be used by the DONA International 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.

signed confidentiality release form received!