Client Evaluation & Response Survey

Client Evaluation & Response Survey - Decatur Doulas

1. Names

Names Your Name
Your Doula's Name
Where did you give birth?
Who was your midwife or doctor?

2. Dates

	MM		DD		YYYY
What is your baby's birthday?	Dates What is your baby's birthday? Month	/	Day	/	Year
Today's Date	Today's Date Month	/	Day	/	Year

3. Please answer the following questions about your doula as accurately as possible. On the scale of 1-10, 1 being poor and 10 excellent.

	1 Poor	2	3	4	5	6	7	8	9	10 Excellent
1. Our doula was helpful at answering questions.	Please answer the following questions about your doula as accurately as possible. On the scale of 1-10, 1 being poor and 10 excellent. 1. Our doula was helpful at answering questions. 1 Poor	2	3	4	5	6	7	8	9	10 Excellent
2. Our doula seemed to have good suggestions during labor and birth.	2. Our doula seemed to have good suggestions during labor and birth. 1 Poor	2	3	4	5	6	7	8	9	10 Excellent
3. Our doula was kind and compassionate.	3. Our doula was kind and compassionate. 1 Poor	2	3	4	5	6	7	8	9	10 Excellent
4. I would recommend using a doula to a friend and other pregnant women.	4. I would recommend using a doula to a friend and other pregnant women. 1 Poor	2	3	4	5	6	7	8	9	10 Excellent
5. Our doula was helpful to my husband/partner.	5. Our doula was helpful to my husband/partner. 1 Poor	2	3	4	5	6	7	8	9	10 Excellent
6. Our doula was helpful to me.	6. Our doula was helpful to me. 1 Poor	2	3	4	5	6	7	8	9	10 Excellent

4. Please describe ways your doula was helpful to you throughout your experience with her. Dads please feel free to comment as well.

Please describe ways your doula was helpful to you throughout your experience with her. Dads please feel free to comment as well.

5. Add any other comments you may have... constructive criticism or words of recommendation are welcome and appreciated. We may use your comments on DecaturDoulas.com or in other communications with future clients.

Add any other comments you may have... constructive criticism or words of recommendation are welcome and appreciated. We may use your comments on DecaturDoulas.com or in other communications with future clients.

6. May future clients contact you as a reference regarding the services of Decatur Doulas?

May future clients contact you as a reference regarding the services of Decatur Doulas? Yes

Other (please specify)