Birth Doula Certification Form

Email(Required)

Pronouns

Today's Date(Required)

Mentors Name(Required)

Date of Birth Support(Required)

How many hours of in-person support?(Required)

Birth Location(Required)

Provider's name(s)(Required)

Client's First name, Partner if applicable *(Required)

Referral or Inquiry Source

Describe the interview process (date, location, duration. How did it go?) *

Any issues around fee/finances/contract?

Describe support in the prenatal period: How was the communication, and what support (or services) did you provide?

Describe your prenatal meeting: What did you cover? How did the meeting(s) feel? Anything you would do differently?

Any risk factors/complications prenatally?

If planned cesarean or induction, state reason/diagnosis

If labor was spontaneous, describe support:

Describe in person early labor support (if applicable)

If birthing at a hospital/ birth center, describe arrival, triage experience (if applicable)

Describe active labor support, if applicable. What did you try, did it help?

List/ describe any interventions during labor

Describe your support (informational, physical, emotional) provided to client around any interventions.

If birth was vaginal, describe 2nd Stage (pushing), including support

If birth was via cesarean, describe situation and your support

Describe 3rd Stage (delivery of the placenta)

Describe immediate postpartum period. How was the client, baby, partner? Describe lactation support if applicable.

Describe communication after leaving the birth location, and in the day(s) after the birth.

Postpartum Visit: how many days after birth? Multiple visits?

Describe your postpartum visit(s). How did it go? What did you cover? Any issues (physical/emotional/lactation) for client or baby?

Any resources/referrals provided?

How do you feel you helped them most during the prenatal period? Anything you'd do differently?

How do you feel you helped them most during the birth? Anything you'd do differently?

How do you feel you helped them most in the postpartum period? Anything you'd do differently?

Any feelings about the relationship/connection with this client/partner/family?

Did you encounter anything new that you'd like to learn more about? *

Any other thoughts about this experience that you'd like to discuss with your mentor?

Birth Doula Certification Review Form