Doula Services Evaluation -Mother

(Download this form as a pdf file here)

It is very important for me to get regular feedback from my clients after their births.  I would appreciate it if you would take a moment and fill out this form.

Mother’s Name:  ____________________________________________________

Baby’ Date of Birth: __________________________________________________

Birth Location: ______________________________________________________

Doula’s Name:  Sabrina Roberson

I would appreciate your taking a moment to evaluate your perception of my role in your birth.  Please circle the number which most closely reflects your opinion of my contribution.  Number five representing the most beneficial.

(Least)                                     (Most)

Were the techniques suggested helpful                   1          2          3          4          5

to you in handling the physical aspects

of your labor?

Were the techniques used helpful to you                 1          2          3          4          5

In handling the emotional aspects of your

labor?

Were the suggestions helpful to the                          1          2          3          4          5
father/partner/family members present

at the labor?

Overall, how would you rate the value                      1          2          3          4          5

And usefulness of having me present at

your birth?

Please add any other additional comments concerning the labor support you received:

Thank you for your comments!