Doula Evaluation - Pittsburgh Bereavement Doulas

Your feedback on the services our Bereavement Doulas provide is important to us. Whether you are a client or hospital/facility staff, we take your thoughts and suggestions seriously. We do our best to anticipate your needs, but want to learn how we can provide impactful service during this difficult time.

Click the appropriate button below to provide feedback and submit your evaluation.

Bereaved Parents

Hospital/Care Provider

Bereavement Doula Evaluation - Bereaved Parent

"*" indicates required fields

Client's Name*

First Last

Bereavement Doula's name*

Please check any of the following ways in which your Bereavement Doula provided labor and birth support:*

Helped me feel empowered

Boosted my confidence

Emotional Support

Kept me informed

Supported other family members

Lessened my fears

Helped me to rest

Physical Support

Other services or support provided

Other services or support provided:

Do you feel your Bereavement Doula helped you prepare for your baby's birth?*

Yes

Do you feel your Bereavement Doula was knowledgeable?*

Yes

How did your Bereavement Doula help you prepare for birth?

How did your Bereavement Doula help you during the birth?

How did your Bereavement Doula help you after the birth?

Please comment on any way you feel your Bereavement Doula did not help.

Please check any way in which your Bereavement Doula helped you after your baby was born:*

Seeing and holding

Emotional recovery

Funeral/memorial support

Support for family, siblings and friends

Memory-making

Information on physical recovery and breast care

Return home and return to work support

Other that is not addressed

Please list actions not addressed above.

Please rate how well your Bereavement Doula helped with the following areas.

Availability and commitment*

Poor	Mediocre	Adequate	Good	Excellent

Knowledge of normal labor*

Poor	Mediocre	Adequate	Good	Excellent

Comfort measures*

Poor	Mediocre	Adequate	Good	Excellent

Cooperation with birthing person's partner*

Poor	Mediocre	Adequate	Good	Excellent

Communication with staff*

Poor	Mediocre	Adequate	Good	Excellent

Support for birthing person's wishes*

Poor	Mediocre	Adequate	Good	Excellent

Suggestions for comfort/progress*

Poor	Mediocre	Adequate	Good	Excellent

Emotional support/reassurance*

Poor	Mediocre	Adequate	Good	Excellent

Professional image*

Poor	Mediocre	Adequate	Good	Excellent

Overall performance/care*

Poor	Mediocre	Adequate	Good	Excellent

What was the most helpful about having a Bereavement Doula?

Were there any areas in which you thought your Bereavement Doula needed improvement?

Do you have any suggestions for improving the Bereavement Doula services or anything else they did not do that you wish had been done?

Bereavement Doula Evaluation - Hospital/Care Provider

"*" indicates required fields

Your Name*

First Last

What was your role/relationship?*

Doctor

Nurse

Midwife

Other

Other Role/Relationship

Hospital/Facility Name*

Parent's Name

Bereavement Doula's Name*

Please click the number which most closely reflects your evaluation of the Bereavement Doula's contribution.

Was the Bereavement Doula's guidance advantageous in preparing the client for the baby's birth?*

Not at all	Some	Adequate	Yes	Very Much

Did the Bereavement Doula provide information that was helpful in the client's decision-making?*

Not at all	Some	Adequate	Yes	Very Much

Did the Bereavement Doula appear to connect with and listen to the client and their needs?*

Not at all	Some	Adequate	Yes	Very Much

Was the Bereavement Doula helpful to other members of the family?*

Not at all	Some	Adequate	Yes	Very Much

Were the Bereavement Doula's suggestions beneficial in making valued memeories?*

Not at all	Some	Adequate	Yes	Very Much

Did the Bereavement Doula provide good resources for the client?*

Not at all	Some	Adequate	Yes	Very Much

Would you rate the services of the Bereavement Doula as positive?*

Not at all	Some	Adequate	Yes	Very Much

Are you satisfied with the quality of support offered by Pittsburgh Bereavement Doulas?*

Yes

Do you believe the services were provided in a professional way?*

Yes

Do you believe the attendance of Pittsburgh Bereavement Doulas was an asset to the family?*

Yes

Do you believe the attendance of Pittsburgh Bereavement Doulas was supportive to the staff?*

Yes

Would you recommend Pittsburgh Bereavement Doulas to another family navigating a loss?*

Yes

Are there areas where you believe that Pittsburgh Bereavement Doulas could have done more (or less)? Please Explain.

Other comments or notes:

Phone

This field is for validation purposes and should be left unchanged.

Did you know?

When you see a purple butterfly on a neonatal cot or incubator, it represents a baby that was part of a multiple pregnancy, but sadly, did not survive.

"The healing power of even the most microscopic exchange with someone who knows in a flash precisely what you're talking about, because she experienced that thing too, cannot be overestimated."

– Cheryl Strayed

Bereavement Doula Evaluation

Bereavement Doula Evaluation - Bereaved Parent

Please rate how well your Bereavement Doula helped with the following areas.

Bereavement Doula Evaluation - Hospital/Care Provider

Please click the number which most closely reflects your evaluation of the Bereavement Doula's contribution.

Did you know?

Photography

Photography Services for Perinatal and Infant Loss

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