18027 Shady Cypress Lane
Cypress, Texas 77429
832-622-8885 (cell)
midwifeshannon@houstoncertifiedmidwife.com
www.houstoncertifiedmidwife.com
Fees for Midwifery Services
The Global Maternity Fee for midwifery services of A Sacred Journey Midwifery Services is $4250. There is a discount for those
patients who pay early, hire a doula and/or take a childbirth class. Previous patients will receive a discounted rate of $3750. There is
also a special rate for those who qualify for Medicaid. Those with other circumstances not mentioned above may qualify for a
scholarship that will reduce fees to ____________. This fee covers all prenatal visits, your birth, postpartum care, newborn exams,
and telephone counseling as needed. This fee does not cover lab work or ultrasounds. (There are a few expenses that the global fee
does not cover. Please see the details listed below.)
Midwife:
The owner of A Sacred Journey Midwifery Services, Shannon Stellhorn, CPM LM is licensed by the State of Texas to practice
independent midwifery as a Licensed Midwife. She has received a formal midwifery education and received clinical training as
outlined by Texas Laws and Statutes. The client has been informed of the credentials of Shannon Stellhorn and her scope of practice;
the risks and benefits of an out-of-hospital birth and the limitations of midwifery care. The client has had ample opportunity to ask any
and all questions pertaining to midwifery care. This is outlined throughout this contract for midwifery services.
Here is a summary of what is included in the global maternity fee:
 All Prenatal Care - including office visits & 1 prenatal home visit at 36 weeks. I see most women once a month until 28
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weeks, every two weeks until 36 weeks, then weekly until the baby is born. Not everyone is the same and some women
require prenatal exams more often.
Nutritional Counseling – including diet education, and discussions on implementing herbs, oils and other nutritional
supplements throughout your pregnancy and postpartum.
Complete care during labor & delivery - I stay with you throughout the labor, delivery, and several hours postpartum.
Even in the unexpected event of a transport to the hospital, I will stay with you until transfer of care is complete.
Postpartum Care through 6 weeks for both mother & baby - This includes a home visit at 48-72 hours (additional as
needed in the first week) and office visits at 2 weeks and 6 weeks. Breastfeeding education and support is included. Pap
smear can be done at 6 week postpartum visit. Will be billed to your insurance.
Group Prenatals – Held once a month. This is a time for all current clients to come together for a class and birth story
time. Classes include breastfeeding, comfort measures, optimal fetal positioning, etc.
Placenta Encapsulation - After delivery, I will deliver your placenta to Trina Evans of Moonlight Doula Services for
encapsulation services. She will encapsulate your placenta and return it to me in time to deliver to you when I come for your
postpartum visit. Many studies show that encapsulation helps women with hormone stabilization, increased milk supply,
increased energy and reduces postpartum depression just to name a few of the benefits.
Birth Assistants - I have at least one birth assistant with me at every birth (sometimes more). Included in your global fee if
payment for a trained birth assistant to accompany me at your delivery. Every birth assistant is CPR and NRP certified.
Any additional assistants at delivery will usually be students and they are free of charge. You are always more than
welcome and encouraged to also hire a doula or other professional labor support for your birth. Please ask for
doulas I recommend.
Expenses that are NOT included in the global fee:
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The Basic Prenatal Lab Work is required by law. I currently refer to Quest Diagnostics to keep your expenses for lab work
to a minimum. Insurance usually pays for labs. If you do not have insurance, you may choose to have Quest bill my
account to keep your costs at a minimum. I will then notify you of the bill. If extra lab services are required or desired,
additional charges will apply. All pap smears and cultures can be done in your home or in my office; again fees are kept to a
minimum. If any labs or cultures are done in my office or your home, they will be sent to MDL.
Personal Birth Kit I will provide you with information on how to order your birth kit. You should order your kit early
enough to have it available for your home visit at 36 weeks. The birth kit contains the consumable items we use for a birth
(sterile gloves, bed pads, etc). The price is usually around $100 and you will be ordering this through In His Hands. You will
also be responsible for ordering the pool liner from In His Hands as well. It is $38. There will also be a need for a few other
items (such as juices, towels, etc). You probably already have most of these things around your home. See your Homebirth
Organizational List in your folder.
Ultrasounds – I use Sonomasters and One Step Diagnostics for all diagnostic ultrasound needs, which are available in 2-D,
3-D and 4-D. The cost of most ultrasounds is around $150, which also includes pictures and a DVD. If you have had a
previous c/section you will be required to have at least one diagnostic ultrasound during your pregnancy to remain in my
care. Ultrasounds are recommended at 20 weeks for the traditional anatomy scan, and at other times at the discretion of the
midwife. Insurance and Medicaid may not be accepted.
Prenatal Vitamins, Supplements and Medications – Good prenatal vitamins are very important for a healthy pregnancy
and baby, I offer a wide variety of supplements in my office by trusted brands, however you are free to purchase your
supplements wherever you choose. Sometimes I recommend additional supplements for different situations. If you ever need
any medications such as antibiotics or Rhogam (for mothers with RH- blood), this will be an extra expense.
Circumcision – Referral will be given to those patients desiring a circumcision. Circumcision runs approximately $350, will
done in your home, and is done at eight days of life or later.
Newborn Hearing Screening – State mandated. I refer all patients to contact fellow midwife Carol Schumacher (281) 5468219 to schedule newborn hearing screen after the birth. She charges $100.
Emergency Expenses – This may include transportation, emergency room and physician expenses, surgery and
medications; or any standard hospital, clinical, physician, nursing, or doula expenses related to the present pregnancy &
postpartum care; or referrals to any other providers should complications and/or transport arises.
Other Important Information
COMPLIMENTARY CONSULTATION: A free initial consultation is provided to determine your eligibility for midwifery
care/home birth. I will discuss with you your general health; risks of childbirth and home birth to the mom and baby; management of
complications in and out-of-hospital setting; your decision and expectations for midwifery care and home birth; a plan for
arrangements for back up medical care and/or transport should the need occur and provide ample opportunity for prospective clients to
ask questions. A Sacred Journey Midwifery Services encourages the client to do research and prepare a list of questions prior to the
initial consultation.
**In the selection and treatment of clients, I rely on the medical history and information provided by the client. The client agrees that
such information will be complete and accurate to the best of her knowledge. The client understands that certain aspects of her health
may preclude her from midwifery care and/or home birth.
ADDITIONAL HOME VISITS: My fee covers postpartum home visits in the first week after birth. Should you need additional
home visits, you will be charged $75 per visit. Should you prefer additional home visits instead of regular office visits, we can discuss
additional fees for this arrangement. The amount will be determined by the time involved and distance traveled. Please feel free to ask
about this option if you are interested in additional home visits.
REPEAT CLIENTS: All Repeat Clients will receive a discounted Global Maternity fee of $3750. This also includes previous
clients that I served as a doula who are now seeking me as their midwife.
FINANCIAL HARDSHIP: I will work with you if you have a genuine financial need. I will help you explore your financial options.
Hopefully, we can find a way for you to meet your obligations and still have the home birth you desire. You only have so many babies
and I want to make this possible for you.
CONSENT TO TREATMENT: The client gives her consent to A Sacred Journey Midwifery Services, Shannon Stellhorn, to care
for and treat her during the course of her pregnancy, birth until conclusion of care at 6 weeks postpartum. This contract will remain in
force until the conclusion of care; the client informs A Sacred Journey Midwifery Services of her intentions to seek care elsewhere or
it is in the clients’ best interest medically to be referred for care due to unforeseen complications. The client agrees to assume full,
personal and legal responsibility for her decision to have an out-of-hospital birth and to prepare accordingly.
RELEASE OF LIABILITY: Before signing this agreement, I (also referred to as client, we, I, they, us or her) have had an
opportunity to discuss A Sacred Journey Midwifery Services’ care and home birth with my spouse, partner or parent, if that parent is a
legal guardian; with a medical care provider or other knowledgeable person, if needed, and with Shannon and ask her questions.
Shannon Stellhorn has discussed her limitations as a midwife; model of care as well as her philosophy with me/us. Shannon Stellhorn
has not represented to the clients that agreeing to her services guarantees in any way a risk free or emergency free labor and birth
experience. We have chosen to have a home birth. We have asked Shannon Stellhorn to assist us in our home birth. The clients (jointly
and separately), the clients’ heirs/family, administrators, personal representative, executors and assigns, release and forever discharge
Shannon Stellhorn’s assistants and any collaborating providers, from all damages or of action, either at law or in equity, which the
clients may have or acquire or which may accrue to the clients or the clients heirs, administrators, personal representatives, executors
or assigns as a result of using the midwifery services of Shannon Stellhorn. The clients intend this to be a complete release and
discharge from all liability whatsoever. The clients are signing a complete release and bar to any claims which the clients have or
believe the clients may have resulting from our agreement for midwifery services. I/We hereby release Shannon Stellhorn, A Sacred
Journey Midwifery Services, her assistants and any collaborating provider(s) from all complications that may arise during the course
of my pregnancy, birth or postpartum as a result of my decisions and my choice to birth my child at home. I/We acknowledge that
Shannon Stellhorn is an independent provider. I/We further acknowledge that I/We have had an opportunity to have any questions
answered regarding the benefits and risks specific to home birth.
PAYMENT ARRANGEMENTS FOR CASH-PAY: The fee for my services may be paid out in installments, including payments in
the postpartum period.
Your initial consultation visit is free. A non-refundable deposit of $600 is due by your first prenatal visit. At that time you will be
given forms for your lab work. You will be asked to sign a financial payment agreement for how you will be paying the remainder of
your fee. Installments may be paid monthly or at each prenatal visit. Special consideration to payment schedules will be made under
certain circumstances. If a client must make payments in the postpartum, remaining balance is due by the end of the first year after
baby’s birth. Minimum payment of $50 must be received by the end of each month. If payment is not received, a $50 fee will be
added to your account for missing a payment. All payments may be made to me, Shannon Stellhorn by cash, check, bank issued
money order, credit/debit card or PayPal. Payments may be mailed to me at: 18027 Shady Cypress Lane, Cypress, Texas 77429. All
returned checks subject to a $25.00 returned check fee. If utilizing a professional doula for your pregnancy and delivery, proof of
payment for services from the doula will be adequate for you to receive $200 discount off my global fee. I also offer a $200 discount
for clients who have gone through an approved childbirth education course during the pregnancy. An early pay discount of $200 can
also be received if paid in full by 28 weeks.
INSURANCE: If you desire any payments to be covered by your insurance, I will assist with filling out any forms necessary. Please
keep in mind, that you, the client are still responsible for the difference regardless of insurance coverage, since midwifery care is
significantly cheaper than hospital care. I also CANNOT guarantee that any insurance will cover midwifery/home birth services.
REFUNDS: Should a client leave my care during the prenatal period electively or due to patient’s risk status changing prior to 36
weeks gestation, a refund will be given based upon the amount of care already received. No refunds will be given after 36 weeks of
pregnancy. The entire fee will apply even in the event of a transfer of care after 36 weeks. A Sacred Journey Midwifery Services,
Shannon Stellhorn, agrees to refund client the amount paid by patient, minus the $600.00 non-refundable deposit, $150.00 per each
prenatal visit and any other balance for lab work and supplements.
I will not refund money in the case of a precipitous delivery or a necessary/elective transport to the hospital during labor or
postpartum. Midwifery services are to make sure you get the best possible birth experience and this includes recognizing and
deciding on the need for transport.
FAILURE TO HONOR YOUR CONTRACT: A Sacred Journey Midwifery Services, Shannon Stellhorn, reserves the right to
terminate services and not attend the birth if full payment is not received as agreed above or if prior arrangements have not been made.
In the event payment is not made and Shannon Stellhorn, withdraws from providing care, she will immediately inform the
client/couple in writing, in person and/or by phone. She will also return any portion of the birth fee which has been paid excluding the
non-refundable deposit of $600.00, $150.00 per each prenatal visit and any outstanding balance for lab work and supplements thus far
in addition to $100/week for any balance that was due beyond the due date.
The client has the right to terminate this contract at any time, for any reason and receive a refund as outlined above. The client agrees
in the event that they chose to terminate this contract for any reason, that they will notify A Sacred Journey Midwifery Services,
Shannon Stellhorn, by phone, by email, or by regular postal service (with return receipt notice).
A Sacred Journey Midwifery Services, further reserves the right to decline care in the event Shannon Stellhorn’s assessment of the
client deems a medical or psychological condition(s) that is not compatible with out of hospital birth or because of
noncompliant/uncooperative actions by the client.
I/We have read the above contract and agree to contract A Sacred Journey Midwifery Services, Shannon Stellhorn, for the services
stated within this agreement. I/We accept the full financial obligation of all services rendered. I/We do hereby understand and accept
all information, terms and conditions as laid out herein. I/We execute this contract voluntarily and with full knowledge of its
significance and ramifications
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Client Signature
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Partner Signature
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Midwife Signature
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