Family & Consumer Sciences
“She, Me, and Her” Maternal Health Program
Client Confidential Data Release Form
I, , give my permission for my doula, , 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 family.
I understand that this information is collected and used by Central State University (CSU) for the purpose of providing doula services as part of CSU’s Extension Doula Program and will be securely shared and stored by the doula and CSU. I also understand that this information will be used anonymously by CSU for reporting and program improvement purposes. I acknowledge that this information will be shared with any doula who is providing backup support, and that I can request my doula provide me with a summary for my own personal use.
