ATM Client Feedback Evaluation Form

Directions to the Client

Please read the following very carefully. Failure to properly follow these directions may result in your opinions NOT being communicated to ATM and/or the midwife.

This evaluation form should only be used by clients of midwives who are current members of ATM. If you do not know if your midwife is a member of ATM, you should ask her or you may send an inquiry to the ATM office   All midwives listed on this site are current members of ATM. However, all members are not listed on our site.  Please complete this form after your birth, being as open and honest as possible in evaluating the care given by the midwife during the prenatal, birth and postpartum periods.

Please read all the instructions below carefully and then fill in the blanks. Use the "send" button when you are finished and the form will be emailed the ATM office. The completed form will then be placed in the midwife's file, and forwarded to the midwife so that she may evaluate her midwifery practice. 

PDF Feedback Form

If you prefer a paper copy of this form which may be mailed to our office, click here for a PDF version which may be printed and used for mailing. The mailing address is included on the paper form.

Important Note: DO NOT use the address at the bottom of the PDF form when mailing the completed form into ATM. Please mail to :

P.O. Box 887, Elmendorf, TX. 78112

Complaints

DO NOT use this form if your intent is to file an official complaint against a midwife. This form is strictly a client feedback evaluation form which was designed by ATM to assist the midwife in improving her own midwifery services. This form is kept strictly confidential and is never used as information for an official complaint review.

If you believe a midwife has broken the law or if you think a midwife might be a risk to yourself or others please contact the Texas Midwifery Program hotline at 1-800-942-5540 to request the appropriate form for complaints or to obtain more information about filing a complaint.

Formulario de Comentarios Español

Haga clic aquí para obtener el formulario de comentarios española en formato PDF.

Online Client Feedback Form

PRENATAL PERIOD:
Discuss the quality of prenatal care received.
Please compare the care from the midwife with care received from others (physicians, clinics, etc) during this or previous pregnancies.
LABOR AND BIRTH
Evaluate the care given to you by the midwife during labor and birth (physical exams, emotional support, etc).
POSTPARTUM PERIOD
MISCELLANEOUS
OTHER
Your answers to the following questions would help us better understand the clientele we serve. However, answering these questions is optional.

Contact Details

Association of Texas Midwives

P.O.Box 887 Elmendorf, TX 78112

Tel: 432-664-8815

Email:  ATMOffice@texasmidwives.com

 

For website related issues, please contact our

Webmaster: webmaster@texasmidwives.com

Social Info/ Links

      

 

Goal Statement

"To advance the quality and accessibility of midwifery in Texas."