Client Feedback Form

In order to provide the best service to our clients, we need your feedback. This evaluation is confidential. Please be thorough and candid, but constructive.

Your Team:		Team 1:    Team 2:
Please answer each question in accordance to:
1 - Strongly Agree 2 - Somewhat Agree 3 - Neutral / Neither Agree or Disagree 4 - Somewhat Disagree 5 - Strongly Disagree
Did you feel that your questions were answered adequatly in the clinic?		1   2   3   4   5
I felt comfortable paging my midwives with questions or concerns.		1   2   3   4   5
My midwives gave me the support and reassurance I needed.		1   2   3   4   5
My partner felt supported adn reasurred by the midwives.		1   2   3   4   5
In labour, I felt secure and confident with my midwives.		1   2   3   4   5
I felt that my midwives listened to my concerns and acted accordingly.		1   2   3   4   5
I felt that I was able to make well informed choices after knowing and discussing my options.		1   2   3   4   5
I felt I had control over my birth regardless of my experience.		1   2   3   4   5
My midwives gave me the help I needed with breastfeeding.		1   2   3   4   5
I felt that there was conflicting advice with some concerns.		1   2   3   4   5
I felt that I received appropriate care and guidance with baby care following our birth.		1   2   3   4   5
I felt the 2 week clinic visit was useful.		1   2   3   4   5
I felt the six week clinic visit was useful.		1   2   3   4   5

OVERALL EVALUATION		1 - Extremely Satisfied 2 - Very Satisfied 3 - Somewhat Satisfied 4 - Neutral 5 - Somewhat Dissatisfied 6 - Very Dissatisfied 7 - Extremely Dissatisfied
Where you satisfied with the front end support staff, (making appointments / answering your phone calls/etc?		1   2   3   4   5   6   7
		Please Explain:
Were you satisfied with the care you received from your midwives?		1   2   3   4   5   6   7
How satisfied are you with the prenatal care that you received?		1   2   3   4   5   6   7
How satisfied are you with the labour and birth care you received?		1   2   3   4   5   6   7
How satisfied are you with the postpartum care you received?		1   2   3   4   5   6   7
Would you recommend our services to a friend or family member?		YES   NO
		Please Explain:
Would you use our services again if you were to have another baby?		YES   NO
		Please Explain:
Additional Comments/Suggestions:
Do you have any suggestions for improvements?

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