Doula Self-Report

CHILDBIRTH ASSISTANT/POSTPARTUM DOULA/BREASTFEEDING PEER COUNSELOR SELF-REPORT

Childbirth Assistant/Postpartum Doula Information:

Counselor's First Name*

Counselor's Last Name*

Street Address*

City*

State*

Zipcode*

Area Code and Phone*

HMHBA Email address*

You will receive a copy of this form at this email address.

Agency / Employer*

Training Type*

In-Person

Online (Zoom, other)

Training Name*

Perinatal Support Specialist Advanced Doula Training

Breastfeeding Peer Counselor Training

Postpartum Doula Training

Other

Training Name

Training Date*

Client Information:

Name of Client*

Client’s Phone Number*

Date of Baby’s Birth*

Location of Support Sessions*

Client’s home

Doctor’s Office/Clinic

Hospital

Other

Number of sessions given*

Age of baby at time of sessions (months)*

1. Please describe the topics discussed, problems you assisted with and how the problem was resolved.

2. Did you make any referrals for this woman and baby? (i.e., to lactation consultant, pediatrician, etc.).

3. How did the mother and baby respond to the support you gave?

4. What did you learn from this experience?

5. What, if anything, would you do differently next time?

6. Is there anything else you want us to know?