Evaluation of Support Services
Name of Doula
First Name
Last Name
Name of (Evaluator)
First Name
Last Name
Role of Evaluator
Birthing Person
Birth Partner
Doctor
Midwife
Nurse
Other
Service(s) Provided
Pregnancy Support
Labor/Birth Support
Post-Partum Support
Other
1. Overall how would you rate the Doula's performance based on your expectations for their role?
Rows
Below Expectations
Meets Expectations
Exceeded
Expectations
Not Applicable
Doula acted in a professional manner
Doula was able to provide resources and materials as needed
Doula provided assistance, reassurance and guidance
Doula interacted with me and my team efficiently
Doula made me feel important and valued
Doula was knowledgeable of appropriate birth practices
Doula demonstrated good listening skills
Doula was responsive to my needs
Doula was responsive to my baby's needs
2. What was the most valuable aspect of your Doula's support?
3. How could your Doula improve their support?
How would you rate your Doula's performance?
1
2
3
4
5
1=Poor 5=Outstanding
Signature
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