Calmbirth Registration Form
For any questions please feel free to contact us via email at info@whitelotusbirthandbeyond.com.au
Email address *
Intended Workshop Dates *
Your answer
Birthing Mother's Name, Age & Occupation *
Your answer
Partner's Name, Age & Occupation *
Your answer
Best Contact Number *
Your answer
Do you have any irrational fears? Eg; Water, heights etc
Your answer
Do you take any regular medications? If so, what?
Your answer
Are you under the care of a psychologist? If you ticked yes- please provide a letter of approval for you to attend Calmbirth class
What number birth is this?
What is your due date?
MM
/
DD
/
YYYY
Name of Doctor or Midwife (if going private)?
Your answer
Hospital or intended birth place?
Your answer
Have you attended any other childbirth preparation classes?
How did you hear about Calmbirth Classes?
Your answer
What are your feelings about the birth prior to attending Calmbirth?
Your answer
What kind of birth would you like to achieve?
Your answer
Is there any specific fear either of you have about the birth or about becoming a parent?
Your answer
Hobbies or interests...
Your answer
DISCLAIMER: The Calmbirth class program includes psychological & emotional preparation for birth. I understand that the delivery of the course will include guided relaxation as a means to facilitate emotional subconscious healing of fear and anxiety about childbirth. *
I understand that I will be required to pay a minimum deposit of $250 upon booking in order to secure my intended dates, with remaining monies due in full no later than 2wks prior to commencement of my workshop. I have reviewed, understand and agree to the cancellation policy on the White Lotus Birth and Beyond website. *
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