Birthing From Within Class Registration Form
All information is confidential. How much and what you share is up to you.
Email address
Birthing person's name
Your answer
Partner's name
Your answer
Estimated due date
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DD
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YYYY
Mailing address
Your answer
Phone(s)
Your answer
Birthing person's age
Your answer
Birthing person's occupation
Your answer
Partner's age
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Partner's occupation
Your answer
Doctor/Midwife
Your answer
Intended birthplace
Your answer
First pregnancy?
Miscarriages?
Fertility issues/IVF?
Your answer
Ages of other children
Your answer
Are you using a doula? If so, whom?
Your answer
Preferred class series (which start date?)
Your answer
What do you already know about the Birthing From Within style of childbirth preparation?
Your answer
Birthing Person: What are you hoping to get out of our time together?
Your answer
Birthing Person: Do you have any specific topics, questions, or concerns you want covered in class?
Your answer
Partner: What are you hoping to get out of our time together?
Your answer
Partner: Do you have any specific topics, questions, or concerns you want covered in class?
Your answer
Is there anything else either of you want me to be aware of?
Your answer
How did you find out about this class?
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Hold your spot with a $50 non-refundable deposit:
The total cost of the class is on a sliding scale of $150-$300 which covers both of you and a copy of the new book "Ancient Map for Modern Birth" by Pam England. My intention behind the sliding scale is to give you an opportunity to go within and ask yourself what amount feels right to you within that range. Listening to our inner guidance is an important task of parenthood. When a number in that range pops into your mind and feels right in your heart and belly, then you know the price. People generally pay the remainder due on the first class, but I'm open to you making payments if that would be helpful. Feel free to suggest a payment schedule, and I'll let you know if I can accommodate that. My birth doula clients can take the class for free.
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A copy of your responses will be emailed to the address you provided.
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