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 support did they provide? (Birth doula, postpartum doula, massage, etc)
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What month and year did they begin care and how long (x# of weeks/months) did they support you?
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In general, how was the support they provided?
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Was there anything that stood out as exceptional?
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Was there anything that concerned you about their care?
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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?
From 1-10 (with 1 being poor and 10 being exceptional), how would you rate their trustworthiness and honesty?
From 1-10 (with 1 being poor and 10 being exceptional), how would you rate their reliability and responsibility?
From 1-10 (with 1 being poor and 10 being exceptional), how would you rate their communication skills?
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!
