Dear Medical Provider:

At New Beginnings Doula Training, in order to better support our students in their work, we have found it beneficial to collaborate with those within the local medical community.

To this end, we request our students find at least two medical professionals to complete this questionnaire. This also allows our trainers to better understand the birthing environment in which our students are working.

Please provide responses to the following questions, and then mail/email your response to the address provided at the end of this form.

Thank you for your willingness to work with our program in this collaborative effort.

Rachel Leavitt RN, BSN, CD
Owner and Lead Trainer

    Doula's Name*:

    Date*:

    1. Are there restrictions on who is allowed in the birthing/triage room?

    2. Are midwives available as care providers in your practice or facility?

    3. Do women have access to information about practices and procedures involving your
    practice or facility, including information about interventions commonly used and
    outcomes?

    4. Are you or your employees trained in providing care for different cultures or groups?

    5. In your practice or facility, are women actively encouraged to walk, move around, or
    assume positions of her choice?

    6. Which of these practices are used in your practice or facility?

    7. Is your staff educated in non-drug methods of pain relief? If yes, how is that education
    given?

    8. What policies do you have to insure that mother and baby are allowed to stay together as
    much as desired, assuming both mother and baby are healthy?

    9. What would help you to be able to better work with doulas in your practice?

    10. Please include the name of your facility (or practice) and location. Thank you for taking the time to help
    with this project.

    Your email address*:

    (We do NOT record, collect, or resell emails submitted on this form. Your email address will be used to send you a personal receipt of the submitted form.)

    Doula student's email address*:

    (This should be provided by the doula student who requested this questionnaire. Please note: the doula student will also receive a copy of the submitted form. The student email address allows us to identify the student for proper credit.)

    * Required Fields