Client's Name *

First Name

Last Name

Partner's Name

If applicable

First Name

Last Name

Phone *

Country

(###)

###

####

Date of Baby's Birth *

MM

DD

YYYY

Are you comfortable with Doula Canada contacting you if they have any questions? *

Yes

No

Were you satisfied with the number of prenatal visits that you received? *

Yes

No, we would have liked more

No, we would have liked less

Did the length of our visits seem: *

Too long

Too short

Appropriate

Was the prenatal support you received consistent and reliable? *

Yes

No

Was I easy to contact when you needed? *

Yes

No

Did you feel comfortable asking questions or making requests of me? *

Yes

No

Somewhat

Do you feel I included both partners equally and considered each partner's concerns effectively? *

Yes

No

Somewhat

Was I easy to contact once you were in labour? *

Yes

No

Somewhat

Did I arrive in a timely fashion once you requested my presence? *

Yes

No

Somewhat

Did I arrive in a professional manner with the tools/aids we discussed? *

Yes

No

Somewhat

Was the support consistent and reliable during labour? *

Yes

No

Somewhat

Do you feel I made it possible for you to make informed decisions? *

Yes

No

Somewhat

Do you feel I supported the decisions you made without judgment or criticism? *

Yes

No

Somewhat

Did you feel comfortable asking questions or making requests of me? *

Yes

No

Somewhat

Did I work to ensure the partner was included in the process to the extent he/she was comfortable?

If applicable

Yes

No

Somewhat

Immediately following birth, do you feel my support to the mother/birthing person was consistent and reliable? *

Yes

No

Somewhat

Did I stay for an appropriate amount of time following birth? *

Yes

No

Somewhat

Was the support consistent and reliable in the period of time after delivery until I departed? *

Yes

No

Somewhat

Did I follow up with you via phone in a sufficient time frame? *

Yes

No

Was your first home visit made within a satisfactory amount of time after your delivery? *

Yes

No

Were your postpartum concerns addressed and referrals made when necessary? *

Yes

No

Somewhat

Were the terms of your contract honoured and followed as discussed? *

Yes

No

Would you consider writing a testimonial of your experience that I can use when prospecting future clients? *

Yes

No