Intake Form
Please fill out this intake form so we can get you started with the classes. We offer the Billings Ovulation Method at no cost for all Catholic women/couples directly through CWCNFP.

For people with eligible insurance, we also offer Billings, Creighton, STM, Marquette, and FEMM at no cost for all women/couples, regardless of religious affiliation, through MyCatholicDoctor. 
Email *
Woman's email
Woman's First Name
*
Woman's Last Name *
Woman's Phone *
Woman's Date of Birth *
MM
/
DD
/
YYYY
Woman's Religion
Marital status
Clear selection
Man's name
Man's date of birth
MM
/
DD
/
YYYY
Man's email
Man's phone
Man's religion
State *
Diocese
Parish
wedding date (if engaged or convalidating)
MM
/
DD
/
YYYY
number of children *
previous family planning (if any) *
What is your reason for using NFP vs contraception?
Immediate plan for NFP
Clear selection
Which method do you prefer? All classes are live over Zoom.
Clear selection
We have a partnership with MyCatholicDoctor that allows us to offer more methods (Billings, Creighton, Sympto-Thermal, Marquette, FEMM, Boston Cross Check) at no cost. It does require eligible insurance (insurance is billed, but you will not receive a bill or be responsible for a copay or deductible or anything). If you would like to go through them, please provide the name of your insurance. (eg: BCBS or Aetna, etc)
If using insurance, please provide the type of insurance (eg: PPO, HMO, POS, etc)
If neither of those is an option, or if we don't have a provider in network with your insurance, we can refer you to a low-cost instructor for Marquette, Creighton, or Billings. Do you want this option?
Clear selection
Is there anything  else you want us to know? If so, please share it here. 
If you would like to speak to an assistant to answer any questions, please let us know. Otherwise we will email you the scheduling information. 
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of ccnfp.org. Report Abuse