Homebirth Midwife Reference

Coming soon: Doula References and Health Care Practitioner References

Please use this form to share your experiences with your homebirth midwife(s). Fill out one form per each midwife team--if you've used the same midwife(s) for more than one birth experience, consolidate the experiences onto one form.

The information you fill out on this form will be put onto a webpage with several other references for homebirth midwives. Only fill out what information you would like to be on that public page. Whatever you type in the field that says "Note for Amy Only" will only go to me and not be accessible to the public.

While I think everyone's experiences are valid, I want to remain respectful to the homebirth midwifery community. If you have strong negative feelings about your midwife(s), please do not post them here; rather, post your contact information and allow individuals to contact you personally. If there are serious/harmful issues surrounding a particular midwife, please contact the appropriate personnel--perhaps starting with Minnesota Families for Midwifery.

I recommend saving what you write in a separate document first so it doesn't get lost while you're filling out this form, just in case. The items with asterisks (*) are required.

Thank you for sharing!

(*)Your First Name:
Your Last Name:
(*)Your City:
(*)Your State:	Choose One:AKALARAZCACOCTDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY
(*)Your Zip:
Your Phone Number:
(*)Your E-mail:
Your Website/Blog:
(*)Date of Baby's Birth:
(*)Your Midwife's First Name:                (*)Your Midwife's Last Name:
If applicable,   Your 2nd Midwife's First Name:                Your 2nd Midwife's Last Name:
If applicable,   Your 3rd Midwife's First Name:                Your 3rd Midwife's Last Name:
If applicable,   Your 4th Midwife's First Name:                Your 4th Midwife's Last Name:
(*)Are you interested in being contacted as a reference for your midwife(s)?	Choose One: Yes No Maybe
(*)What number birth was this for you?	Choose One: 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th
How many weeks pregnant were you when you selected this midwife(s)?	Choose One: prior to pregnancy 1 week 2 weeks 3 weeks 4 weeks 5 weeks 6 weeks 7 weeks 8 weeks 9 weeks 10 weeks 11 weeks 12 weeks 13 weeks 14 weeks 15 weeks 16 weeks 17 weeks 18 weeks 19 weeks 20 weeks 21 weeks 22 weeks 23 weeks 24 weeks 25 weeks 26 weeks 27 weeks 28 weeks 29 weeks 30 weeks 31 weeks 32 weeks 33 weeks 34 weeks 35 weeks 36 weeks 37 weeks 38 weeks 39 weeks 40 weeks 40-plus weeks
Briefly describe your personality:
What were the five most important things you and your family were looking for with your homebirth and midwife:	homebirth/midwife importance: number 1 -     homebirth/midwife importance: number 2 -     homebirth/midwife importance: number 3 -     homebirth/midwife importance: number 4 -     homebirth/midwife importance: number 5 -
Were you reimbursed by your insurance for the cost of the midwifery services?	Choose One: Yes No It's in progress I don't know yet
If you have been or will be reimbursed for the midwifery services, for what percentage and with which insurance company was/will be reimbursed?
What tips do you have for insurance reimbursement?
Did you want a licensed or unlicensed midwife?	Choose One: Licensed Unlicensed Did Not Matter
Pertaining to licensing question above: why?
Did you select a back-up hospital or doctor?	Choose One: Yes No
If you selected a back-up hospital or doctor, which/whom did you select; and why?
If you transported to a hospital for your birth, you may write about it here:
Did you hire a doula?	Choose One: Yes No
Pertaining to doula question above: why did or didn't you hire a doula, and do you recommend it?
Did you have a waterbirth?	Choose One: Yes No
If you had a waterbirth, from where did you get your birthtub? Please add any other comments pertaining waterbirth here:
Did you have the birth experience you wanted?
(*)What did you appreciate / like about your birth experience?
What would you have liked to change about your birth experience?
Do you feel closure with this birth experience?
What suggestions and tips do you have pertaining to homebirths, etc.? (Include information like what supplies, birth resources, books, and websites you recommend; where you bought your supplies; how you planned for your birth; if you created a birthplan and so on.)

Note for Amy Only:

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