1. GENERAL INFO Mother's Name * First Name Last Name Email Address * Phone * (###) ### #### Estimated Due Date * MM DD YYYY Is this your first baby or 2nd, 3rd, etc. Partner's Name (if applicable) Partner's Phone (###) ### #### Partner's Email Address Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact * First Name Last Name Phone * (###) ### #### Care Provider Birth Doula and/or Postpartum Doula (if applicable) Birthing Location Address Address 1 Address 2 City State/Province Zip/Postal Code Country Have you taken a tour of your birthing location? Yes No I'm planning too Have you or are you planning on taking any additional childbirth classes? If so, please list: What are your overall feelings about labor? Imagine your ideal birth, what makes it ideal? What are you hoping to get out of this class? 2. Curriculum Please list the topics 1-11 based on importance for you (1 - Most important, 11 - Not sure but sounds interesting) Prenatal Prep for Labor 1 2 3 4 5 6 7 8 9 10 11 Signs of Labor beginning 1 2 3 4 5 6 7 8 9 10 11 The Stages of Labor 1 2 3 4 5 6 7 8 9 10 11 Comfort Measures and Coping Techniques 1 2 3 4 5 6 7 8 9 10 11 Labor & Pushing positions 1 2 3 4 5 6 7 8 9 10 11 Relaxation Tools 1 2 3 4 5 6 7 8 9 10 11 Common Medicines & Alternatives 1 2 3 4 5 6 7 8 9 10 11 Common Interventions 1 2 3 4 5 6 7 8 9 10 11 Building Your Birth plan and Team 1 2 3 4 5 6 7 8 9 10 11 Routine Newborn Care 1 2 3 4 5 6 7 8 9 10 11 Breastfeeding Basics 1 2 3 4 5 6 7 8 9 10 11 How did you hear about my workshop?! Friend Family Care Provider Doula Website Instagram Facebook Google Yelp Other Please tell me who I should thank =) Friend, family, provider, doula, etc. Thank you for providing your information!
