Postpartum Doula Certification Review Form

Name(Required)

First Last

Email(Required)

Pronouns

Today's Date(Required)

Mentors Name(Required)

Mentor Program Year(Required)

Starting your practice (year 1)

Advancing your practice (year 2)

Mastering your practice (year 3)

Client's First name *(Required)

Referral or Inquiry Source

Hired Prenatally or Postpartum?(Required)

If hired prenatally, describe any services provided (education, referrals, nursery setup, nutritional planning, etc.)

Was this also your birth client?

Yes

No

Describe Interview (in person/telephone/email/Zoom?) Process if Applicable.

Any issues around fee/finances/contract?

Dates of services (with hourly increments)

Describe the first session: What were the needs communicated, and how did you help?

Describe subsequent sessions. Did the family's needs change, and how did you help?

Any resources/referrals provided?

Describe your connection/relationship with the family members. Any challenges?

Describe your "exit" with this family, how did it end?

Is there anything you'd do differently?

Is there anything you would like to learn more about, that might have helped your support of this family?

Anything else you would like to discuss with your mentor, relative to this client/family?