ATM Client Feedback Evaluation Form
For a
Spanish
feedback form in PDF format, CLICK HERE
Directions
TO THE CLIENT
:
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 our
bookkeeper
. (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 to our bookkeeper. The completed form will then be
placed in the midwife's file. All completed forms are kept strictly confidential.
When several forms are collected for a particular midwife, they are then mailed
to her so that she may evaluate her midwifery practice. 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.
PLEASE NOTE:
DO NOT
use this particular 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.
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