Hypnobirthing Registration: Mom’s Form – Wellspring Hypnotherapy and EFT Center

Name

Email *

Mailing Address

Phone

Date of Birth

Your Baby's Due Date

Class you are interested in (eg Private, Video Package, Both, Don't Know)

How did you hear about these classes?

What has your pregnancy been like so far?

Who is providing your prenatal care and where will you be having your baby?

On a scale of 1 (least compatible) to 10 (most compatible), how compatible are your doctors' or midwives' philosophies and procedures with your own beliefs about birth?

Are you taking other childbirth classes? If yes, where and when?

Have you given birth previously? If yes, when?

If yes, please describe your experience.

Be as brief or as detailed as you wish. Knowing about your previous birth experiences will help me better understand how I might help you.

Have you attended any births other than your own? If so, what was that like for you?

Who do you plan to have at your birth and what involvement would you (ideally) like them to have?

In thinking ahead to your baby's birth, what things do you hope for, or fear, about this experience?

Have you ever used hypnosis, meditation, progressive relaxation or visualization? If yes, please describe.

What is the nature of your work (employment) and/or other hobbies or interests?

Is there anything else I should know about you to allow me to support you as much as possible?

Phone