Doula Services Evaluation -Partner

(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.

Partner’s Comments

Mother’s Name:  ____________________________________________________

Your 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)

Was my presence at your birth beneficial                 1          2          3          4          5

and helpful to you as the partner?

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

in handling the emotional aspects of your

wife/partner’s labor?

Were you comfortable with the role I                          1          2          3          4          5

played, in unison with your participation?

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 and your wife/partner received:

Thank you for your comments!