First and Last Name
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Email
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Phone
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(###)
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Name of practitioner you’re providing a reference for
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What type of relationship did you have with this person?
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If you worked together, what was their role and what was your role?
If you worked together, what timeframe did they work with you? If they're not working with you now, why not?
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Was there anything about them that stood out as exceptional?
Are you aware of any reason they shouldn’t work with moms and babies?
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From 1-10 (with 1 being poor and 10 being exceptional), how would you rate their safety habits and judgment?
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From 1-10 (with 1 being poor and 10 being exceptional), how would you rate their general attitude and emotional maturity?
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From 1-10 (with 1 being poor and 10 being exceptional), how would you rate their trustworthiness and honesty?
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From 1-10 (with 1 being poor and 10 being exceptional), how would you rate their reliability and responsibility?
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From 1-10 (with 1 being poor and 10 being exceptional), how would you rate their communication skills?
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Depending on your answers we may want to talk on the phone, are you comfortable with us setting up a time to talk if needed?
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If you have anything else to add, please feel free to add it here!
