The Newborn Care Agency
Postpartum Doula/Newborn Care specialist
Reference Check Form
What is your phone number in case we have additional questions?
Who are you completing this form for?
What type of care was provided?
24 hour support
A combination of day and overnight support
Did the provider help you with any of the following? (please check all that apply)
Teaching me about my newborn
Assisted in educating my partner or family members about caring for a newborn
Assisting me in managing multiples (twins, triplets)
Assisting with older siblings
Assisting with household tasks
Connecting me with local resources such as lactation consultants, housekeepers, other services
Providing care for the baby so I could rest, take a shower, take care of myself
In what ways was the provider most helpful to you as a new parent?
Did you feel the provider was knowledgeable on topics pertaining to newborns and new parents?
Was there anything you feel the provider could use more training on or experience with?
Any additional notes: