Evaluation Form

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Please take a moment to evaluate the services you received from your doula. These are required as part of our certification with Birth Arts International, and are also vital to our growth as birth professionals! One critical way we improve our practices is hearing what works, and what doesn't, from the families we work for. Thank you!

Your Name *

First

Last

Phone Number *

Email *

Date of Birth *

Location of Birth *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Medical Care Provider Name *

May Birth Arts International contact you about your experiences? *

Yes No

Doula's Name *

First

Last

What did you like most about your doula's service? *

In what areas could your doula improve? *

How do you feel about the time you spent with your doula during prenatal appointments? *

Do you feel that having a doula was beneficial to your birth process? *

Yes No

Would you reccommend your doula to other expectant mothers? Why or why not? *

Any additional comments *

Overall, how satisfied with your doula's service? *

Very Satisfied Satisfied Neutral Unsatisfied Very Unsatisfied

Please describe your overall birth experience? *

Were the doula's suggestions helpful to you and your family? *

Yes No

Would you be interested in being a reference for your doula? (This means she would give your contact information out to prospective clients so they may contact you about her services) *

Yes No

If yes, contact information you would like shared.(Select all that apply) *

Name Phone Number Email Other

Thank you! If you have any questions, please contact Birth Arts International at 866.303.4372 or Demetria@birtharts.com . Demetria Clark BAI 51 Redemption Rock Trail North Princeton, MA 01541

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Lucina's Blessings proudly serves the following towns and counties: Pottstown, Reading, Exton, Royersford, Lancaster, Ephrata,
Limerick, Phoenixville, Chester County, Montgomery County, Berks County, Lancaster County.