Feedback Form
Mother's Name *

First
Last
Partner's Name

First
Last
Your Email *
Where did you give birth?
Who was your Baby Catcher?
Your Baby's Birthday *

MM 		/
DD 		/
YYYY
How would you rate our prenatal visits together? *
 Fantastic! 
 Very Informative 
 OK 
 Expected More 
 Really Disappointed 
Were the techniques I suggested helpful in handling the PHYSICAL aspects of labor? *
 Yes, very helpful 
 Yes, somewhat helpful 
 Not sure 
 No, not at all 
 Does not apply 
Were the techniques I suggested helpful in handling the EMOTIONAL aspects of labor? *
 Yes, very helpful 
 Yes, somewhat helpful 
 Not sure 
 No, not at all 
 Does not apply 
Do you feel that having a doula present during your labor and birth was beneficial to you? Please explain. *
Overall, how would you rate my services? *
 Wonderful  
 Good 
 OK 
 Expected More 
 Really Disappointed 

ADDITIONAL INFORMATION / Please fill this section out if you feel inspired or you want to give more feedback.

Is there anything that could have been done differently?
Do you have any additional observations or comments?
If you used the TENS unit during your labor, please describe how this helped you.
If you would like to provide a testimonial for my website, please write it here and I will add it to my list of happy families :~)

Thank you so much for doing this!