Doula/Breastfeeding Counselor Self-Report for Certification

Doula/Breastfeeding Counselor Self-Report for Certification

Happy Mama Healthy Baby Alliance
Doula/Breastfeeding Counselor Information:
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date of Training*

MonthDayYear
Date
Location of Training*
Client Information:
Client Name*

First NameLast Name
Client Phone Number
Please enter a valid phone number.
Baby's Date of Birth*

MonthDayYear
Date
Support Sessions Information:
Location of Support Sessions:*

Client's HomeDoctor's Office/ClinicHospitalOther
Number of sessions given: *
Age of baby at time of sessions:*
1. Please describe the topics discussed, problems you assisted with and how the problem was resolved. *
2. Did you make any referrals for this woman and baby? (i.e., to lactation consultant, pediatrician, etc.). *
3. How did the mother and baby respond to the support you gave? *
4. What did you learn from this experience? *
5. What, if anything, would you do differently next time?
6. Is there anything else you want us to know?
Signature*

Clear
Cordelia Hanna
Happy Mama Healthy Baby Alliance
600 Lincoln Ave. #92495
Pasadena, CA 91109
Email: cordelia.hanna@motherbabysupport.net
Phone: (626) 388-2191 ext. 3
Should be Empty: