Assessing Care in the Hospital - A Birthmom's Perspective

If you have more to share, feel free to email Rebecca at RVahle@familytofamilysupport.org

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* 1. What year did you give birth?

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* 2. Overall my hospital experience was...

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* 3. Did you fill out the birth certificate information for your child?

Yes

I don't know who filled it out.

If no, do you know who did? (if so, please specify)

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* 4. Who was listed as the "guarantor" for your hospital bill? (ie. were you listed liable for your hospital charges?)

I was as the Mom

The adoption agency was listed and paid my bills

The attorney was listed and paid my bills

The adoptive family was listed and paid my bills

I don't know how I was registered in the billing department

My insurance paid my medical bills

Medicaid paid my bills

Other arrangement?

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* 5. What role did the nurses play in your hospital time? ie. Were they just there to take care of your physically? Did any of them try to give you emotional support?

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* 6. Did you feel pressured in any way by comments or questions? If so, what specifically was said?

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* 7. How much time did you spend with your child?

I didn't spend any time with him or her

I spent the entire time with him or her

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 8. If you could go back, how would you change your hospital time with your child?

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* 9. Anything else you want to add?

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* 10. If anything written above is used in any materials, how would you like to be named?*

Anonymous

Name you'd want used?

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* 11. Are you available for any follow up questions I might have?*

If yes, Email: