FQHC Baseline Survey

  • MOMCHA PROGRAM

    FQHC BASELINE SURVEY

    PURPOSE: The purpose of this survey is to have an understanding of the FQHC's utilization and understanding of doulas. 

    ESTIMATED TIME TO COMPLETE: 3 minutes

    INSTRUCTIONS: Please answer honestly and completely. When selecting an OTHER checkbox, please enter text in the box provided.

  • Demographic Info: Which FQHC do you work with currently?

  • I. DOULA SERVICES: EDUCATION AND AWARENESS

  • 1. Do you understand the role of a doula?
  • 2. Do you know the benefits of having a doula on a maternity care team?
  • 3. Are you interested in enhancing your knowledge about doulas and their services?
  • 4. What do you want to learn or know more about doulas? (Select all that apply)
  • 5. Where did your organization first hear about doulas?
  • 6. Are you aware of the expanded benefit provisions under Medicaid Managed care in Florida that offer doula services for recipients?
  • 7. Are there any barriers that would prevent your organization from referring clients to a doula?

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    II. DOULA CARE COORDINATION AND REFERRALS

  • 9. Does your organization offer telehealth for doula services?
  • 10. In the past, have you partnered with a doula or doula service before?
  • 11. Do you currently refer your patients to a doula or doula service?
  • 12. Do you know where to easily find doulas or doula services for your patients?
  • 13. How often do you refer your patients to doula services throughout the year?
  • 14. When is the doula engaged in the patient's care plan?
  • 15. What methods do you use for patient referrals?
  • 16. Do you provide follow-up care to the patient once a referral has been completed?
  • 17. Have your patients requested to use a doula or doula services during their pregnancy term?
  • 18. How likely would you have a doula on the patient's pregnancy and labor support team at your facility?
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  • Should be Empty: