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Doula After-Visit Form
Instructions for Filling Out this Survey
Please complete this after-visit summary following each interaction with clients assigned to you as part of the Healthy Children’s Fund (HCF) Pilot Doula Project. This data collection is required for your contract and helps us evaluate the Healthy Children’s Fund. Thanks for your contribution! A copy of your submitted surveys will be sent weekly to aid your record-keeping.
1) Choose the correct Client ID from the drop-down menu. The Client ID is assigned when you receive the referral.
2) Select the date and time of the appointment or interaction.
3) Select the type of activity. When Labor Support is chosen, you will be asked to provide additional information about the birth at the end of the survey.
4) Select the activity format, whether in-person, text, email, or phone call.
5) Provide the total amount of time spent in minutes. Please round to the nearest 15-minute increment.
6) From the list provided, check all the support services provided. Please use the section for additional comments to capture any services or situations not listed.
7) If the visit included labor and delivery support, please supply the following: birth weight in grams, gestational age in weeks, birth setting, length of labor, whether delivery included induction, epidural use, or cesarean, breastfeeding initiation, and whether a NICU or special care nursery stay was needed.
