Name: |
Email Address: |
Address: |
City: |
State: |
Zip Code: |
Day Phone: |
Evening Phone: |
How did you
hear about HypnoBirthing? |
Age: |
Marital Status: |
Type of Employment: |
Is this your
first pregnancy? |
Do
you have any other children? Describe, name(s), and ages
|
If
you have had other children, what was your birthing plan, if any,
briefly, describe:
|
Was it a satisfactory
plan? |
How
would you improve it, if it were to be ideal?
|
| What
are your most pressing concerns regarding: |
Your labor? |
Your delivery? |
Your Postpartum
period of time? |
Have
you explored other plans for coping with labor & delivery, if
so, what are they?
|
Have
you had any previous experience with hypnosis, if so, please describe.
|
Name of Your
Current Gynecologist or Midwife |
If Group Practice,
Name the Practice |
If Midwife,
Name of Midwife |
Street Address: |
City: |
State: |
Zip Code: |
Phone: |
Where you will
be giving birth: |
It
is important that you have a birth companion, i.e. husband, father
of the baby, mother, sister, friend or professional birth assistant.
Do you know now who will be attending your birth, if so, please
indicate who that is and if that person or persons will be available
to attend class with you for the training.
|
Do
you have birthing plan? If yes, what is it?
|
Have you discussed
your birthing plan with your doctor? |
If you do not
have a birthing plan, that is fine, it is part of the course to
help you develop one.
|
| Registration |
Course
Time & Place You are Registering For: |
or Number of Individual Sessions: |
Fee Being Paid: |
Type
of Payment
(We Accept Visa/MC/Amex/ Discover, Debit Card/Checks & Cash) |
Card Number: |
Exp Date: |
CVV
Code (the last 3-digits on back of card): |
Name as it appears on the Card: |
Type of Card: Amex Visa MC Discover |
Address of Cardholder, if different from above:
|