Client Evaluation Form The Spanish Version is here. EVALUATION OF BIRTH DOULA OR POSTPARTUM DOULA Instructions: Please take a few minutes to fill out this evaluation about the support you received from the birth doula or postpartum doula.Doula’s InformationDoula First Name*Doulas HMHBA email address*Doula Last Name* Mother’s Information Mother's First Name *Mother's Last Name *Date of Baby’s Birth *Your Phone Number *Mother's Email address*Where did you have your baby? (Name of Hospital or Birth Center)*Doctor or Midwife’s NameDoula Evaluation1. Did the doula meet with you before the birth? *YesNoNumber of visits2. Did the doula help you after the birth? *YesNoNumber of Visits3. Where did the visits take place?*Check all that apply.Hospital/Birth Center Home Clinic/Doctor’s/Midwife’s Office Zoom Meeting4. What time did the visits take place?5. How satisfied are you with the support provided by your doula?*Extremely satisfiedVery satisfiedSatisfiedSlightly dissatisified Not satisified at allCan you explain further why you are not satisified?6. Did the Doula meet your expectations?*Exceeded my expectationsAbove my expectationsMet my expectationsSlightly below my expectationsFar below my expectationsWhat were your expectations and how did your doula not meet them?7. How did the doula help you? 8. Did you need additional support? If so, who else helped you (doctor, nurse, family member, breastfeeding counselor, etc.)? 9. What were the doula’s strengths? 8. Do you have any suggestions on ways the doula could improve her support? 9. Would you recommend this doula? *YesNo10. How likely are you to recommend Happy Mama Healthy Baby Alliance to someone?*Very likelyLikelyNeutralNot likelyVery unlikely11. Did you attend the childbirth preparation class 'Empowered Birth Choices' that we offer?YesNoExplain why you did not attend. (Check all that apply.)The time was not convenient.I didn't know about the classes.I took classes elsewhere. I didn't think taking it was important.I don't have internet access.I couldn't attend all four classes.The classes are too long.12. Would you be interested in participating in a discussion group about your maternity care experience and our doulas?*YesNoMaybe - ask me later13. Do you need any additional help or information? If so, please let us know what we can do for you.*SendThis field should be left blank
