JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Breech Directory (public)
Breech Without Borders is creating a public Breech Provider Directory to help connect families expecting breech babies with local breech providers and allied health professionals. (If you'd prefer to be listed on our private directory, please visit
bit.ly/breechdirectory-form
.)
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Name
*
Your answer
Title and certifications (MD, midwife, traditional bith attendant, doula, chiropractor, etc)
*
Your answer
Country
*
Your answer
State/province/region (if not applicable, write "NA")
*
Your answer
City
*
Your answer
Email
*
Your answer
Phone number
Your answer
Website
Your answer
Social media contact info (FB, IG, etc)
Your answer
Practice setting (mark all that apply)
*
Hospital
Freestanding birth center / freestanding midwifery unit
Home
Required
If you accept insurance, are there certain insurance plans you can or cannot accept?
Your answer
Do you accept late client transfers (e.g., someone who has discovered at 37 weeks that she has a breech presentation)?
*
Yes
No; I only attend breeches for clients I have been seeing throughout their entire pregnancy
Maybe
If you attend home births, how far of a radius do you serve? (Please specify whether miles or km)
Your answer
If you are a birth attendant, are you able to travel (out of state/country) to attend VBBs?
*
Yes
No
Maybe
N/A--not a birth attendant
Do you accept clients who may be traveling from out of state/country to birth with you?
Yes; clients will need to find their own accommodations
Yes; I have on-site accommodations available
Maybe
No
Clear selection
Any other relevant information you'd like to share on the public directory
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Breech Without Borders.
Does this form look suspicious?
Report
Forms
Help and feedback
Help Forms improve
Report