Evaluation of Labor Support Services
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Mother's Name
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Partner's Name
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Baby's Name
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Email
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Birth Day!
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Hospital & Care Provider
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Overall, how would you rate my services *
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Very good
Good
Neutral
Bad
Very Bad
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Were the techniques I suggested helpful in handling the physical aspects of labor? *
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Yes, Very
Helpful
Yes, Somewhat
Helpful
Neither Helped Nor
Hurt
No, Not Helpful at
All
No, They Did
More Harm Than Good
Not Applicable
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Were the techniques I used helpful in handling the emotional aspects of labor? *
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Yes, Very
Helpful
Yes, Someone
Helful
Neither Helped Nor
Hurt
No, Not Helpful at
All
No, Did More Harm
Than Good
Not Applicable
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Overall, how would you evaluate the usefulness of having me present at your labor and birth? *
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Very Usefull
Somewhat Useful
Neither Helped Nor
Hurt
Not Useful at
All
Did More Harm Than
Good
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Additional Information (Optional)
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Is there anything I could have done differently?
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Any additional comments or suggestions?
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If you would like to leave a testimonial for my website please write it here.
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I occasionally have potential clients that would like to speak to past clients, would you like to be included in my rotating referral
list?
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Yes
No
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Phone number for potential clients to call
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Email address for potential clients to use.
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