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Lamaze Childbirth Education Intake Form (Group)
Thank you for choosing Modesto Birth & Beyond for your Lamaze Childbirth Education. Please read through and fill out the following form to enroll in the monthly series you would like to be able to attend.  The classes are most beneficial to be taken starting around 28 weeks and should be completed by 36 weeks. If you have questions, please contact Sheila at 209-576-5450 or email to hello@modestobirthandbeyond.com. 

Our class series of three are held monthly on Thursday evenings from 6-9 pm. Depending on interest, we are also considering a monthly Super Saturday with BOTH Birth Prep classes only. This will be all day with an hour break (6 hours of class time). Please verify when enrolling what dates the classes will be held for the preferred series. We ask that you select a first choice & second choice for your class series. Total hours are 8-9, depending on the size of our class (which is limited). Because we are birth doulas, we keep the fourth week each month as a float in case we need to reschedule one class, however, we usually have a backup doula on call for our classes. 

We suggest expectant parents take all three classes, but we do have other options. The cost for our series of all three group classes is $250, (or $350 for private classes using a separate enrollment form) which includes a Breastfeeding + Newborn Care class. If you would like to just do the two Birth Classes, Anatomy + Physiology of Birth and Comfort Measures + Relaxation Techniques, the cost is $200, or ONLY the Breastfeeding + Newborn Care is $125. Please submit a $75 non-refundable deposit via Zelle: hello@modestobirthandbeyond.com at the time of enrollment & submission of this form. The balance is due at your first class. For your convenience, our MBB Zelle QR code is shown at the end of this form. 

Location for classes is usually at a residence or office in Modesto, or sometimes Oakdale or Manteca. Please confirm address before each class. Questions can be texted to 209-576-5450.

*Please note: Class sizes are limited. Please confirm availability in the group class you are hoping to attend. Submission of this form does not confirm any contract between you and Modesto Birth & Beyond. Clients are taken on a first come first serve basis from when this enrollment form and deposit are received.
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Email *
Promo Code (BLACK Friday weekend only)
Which classes are you enrolling in? *
Month preferred for Class Series (First Choice) *
Which Year? *
Which month is your second choice? *
Which time is better for you?  *
Which year? *
Client Name *
Date of Birth *
MM
/
DD
/
YYYY
Client Mobile Phone *
Home Address (Please include City & ZIP Code) *
Client occupation & hours per week.
Name of Birth Partner
How did you first hear about Modesto Birth & Beyond? Please be specific so we can thank them. 
 *
Required
If applicable, whom can we thank for your referral?
Estimated Due Date *
MM
/
DD
/
YYYY
Baby’s Gender *
Delivery Location *
Care Provider (Midwife or OB) *
Number of Pregnancies
Have you experienced issues related to infertility, hormone imbalance, or PCOS (polycystic ovarian syndrome)? If yes, please explain.
Have you experienced a pregnancy loss, miscarriage, or stillbirth?
Please share some details about previous deliveries: How many weeks were you? Was the delivery induced/augmented? How long did you labor?
In your previous deliveries were there any complications? Did you use pain medications? What were your coping techniques?
How do you feel about your chosen doctor/midwife and place of birth?
Has this been a healthy pregnancy? If not, please explain:  
Is this pregnancy considered high risk?
What kind of birth are you hoping for or expecting?
What has influenced your understanding of how birth goes or the choices you are making for this birth? Friends? Family? Media? Books?
Do you have any concerns or fears at this point about this pregnancy or upcoming birth?
If you have fears or concerns about this delivery, please let us know on a scale from 1-10 how much this fear or concern is affecting you (1 being very minor, 10 being overwhelming).
Clear selection
Who will be present for your birth journey?
Do you feel supported by each person you are including?
What kind of relaxation tools and methods are appealing to you?
What kinds of things do you already do to relax?
What kinds of things does your partner already do to help you relax? Does it typically work for you?
Is there something specific you would like your partner to learn to do?
What's your top TWO "love languages?” What kind of things make you feel loved and appreciated?
What are you hoping to learn in these classes?
Do you have any fears or concerns you would like to discuss with us?
How much do you want to be a part of the decision making process?
Clear selection
How strongly do you feel about the above answer?
Unsure
Adamant
Clear selection
What is your preference for using an epidural
Absolutely don't want one
Definitely want one
Clear selection
Do you plan to breastfeed?
Clear selection
Have you had difficulty breastfeeding in the past?
Clear selection
Anything else you would like to share with us?
Zelle QR Code for MBB (hello@modestobirthandbeyond.com). 
Please list name payment will be under. 
 *
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A copy of your responses will be emailed to the address you provided.
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