Name:

Email Address:

Address:

City:

State:

Zip Code:

Day Phone:

Evening Phone:

How did you hear about HypnoBirthing?

Age:

Marital Status:

Type of Employment:

Due date:

Is this your first pregnancy?

Do you have any other children? Describe, name(s), and ages

If you have had other children, what was your birthing plan, if any, briefly, describe:

Was it a satisfactory plan?

How would you improve it, if it were to be ideal?

What are your most pressing concerns regarding:

Your labor?

Your delivery?

Your Postpartum period of time?

Have you explored other plans for coping with labor & delivery, if so, what are they?

Have you had any previous experience with hypnosis, if so, please describe.

Name of Your Current Gynecologist or Midwife

If Group Practice, Name the Practice

If Midwife, Name of Midwife

Street Address:

City:

State:

Zip Code:

Phone:

Where you will be giving birth:

It is important that you have a birth companion, i.e. husband, father of the baby, mother, sister, friend or professional birth assistant. Do you know now who will be attending your birth, if so, please indicate who that is and if that person or persons will be available to attend class with you for the training.

Do you have birthing plan? If yes, what is it?

Have you discussed your birthing plan with your doctor?

If you do not have a birthing plan, that is fine, it is part of the course to help you develop one.

Registration

Course Time & Place You are Registering For:

or Number of Individual Sessions:

Fee Being Paid:

Type of Payment (We Accept Visa/MC/Amex/ Discover, Debit Card/Checks & Cash)

Card Number:

Exp Date:

CVV Code (the last 3-digits on back of card):

Name as it appears on the Card:

Type of Card: Amex Visa MC Discover

Address of Cardholder, if different from above: