Hypnobirthing Enquiry Form
Full Name: *
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Known as: *
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D.O.B: *
dd/mm/yyyy
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Address: *
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Tel No: *
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Email: *
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Relationship Status: *
Single / married / divorced / separated
Partner’s Name:
If applicable
Your answer
Will your partner be attending the classes with you? *
Do you have any children? *
If Yes, please give names and ages:
Your answer
How did you hear about me? *
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Midwife’s Name: *
Your answer
Midwife’s Address (or Dr’s Surgery):
Your answer
Other Professional Support:
If applicable
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Are you taking any medication? *
Details:
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Are you undergoing any other relevant treatment? *
Details:
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Have you sought assistance from a Hypnotherapist before? *
Details:
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How many weeks pregnant are you? *
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When is your baby due? *
dd/mm/yyyy
Your answer
Do you have any specific reasons for wishing to learn ‘Hypnosis for Childbirth’ techniques? Please give relevant details:
ie Previous birthing experience / anxiety / etc.
Your answer
What kind of birth are you planning for? eg Home / hospital / caesarean / natural / drug free / etc. Please give relevant details: *
Your answer
What are your expectations of coming to the sessions? *
Your answer
Are there any other issues you feel may be relevant to your treatment / training?:
eg Gestational diabetes / pre-eclampsia / hypertension / history of anxiety / depression / etc? Please give relevant details
Your answer
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